CIHM 

Microfiche 

Series 

(Monographs) 


iCMH 

Collection  de 

microfiches 

(inonogriq»hies) 


Cmm«mi  ImtituM  for  Hictorical  Mterorapreductions 


/  Inttitut  Canadian  da  microraproductiona  hiatoriquaa 


TtdwUcal  and  BIMIupnilite  tttm  I  WWW  liUmUBii  t  M>tlmnpliHMi 


The  Imtituta  hn  iWmpfd  to  obtain  Km  b«t  orifiMi 
copy  avaitabit  for  filmint.  FaMitraaa#M(M«VwM* 
may  ba  WMwraphieaily  imiqua,  Mrtiicti  may  after  aay 
ol  tha  iwipi  bi  tba  ripro<iiWiBii.  or  wWah  way 


L'lnttHMt  a  nnietofitai*  la  maiUaiir  axamplaira  qu'il 
taioMpoariMa*«p«wiMW.  LaaMMiirtiMl 
axamplaira  qui  «ont  pMit-ftra  ufiiquat  4m  pefait  da  WK 
biblioyapliiQiia«  ^fA  paiivant  MMdif  iar  una  imafa 
raproAritit  Wi  4bi  pawant  axipar  una  HMdif  icatioii 

ei-danoin. 


0 Coloured  covart/ 
Cottvartura  da  eouleur 


0 


Covert 
Couvertura 


□ Covara 
CuMtartura 


and/or  law  im lad/ 


□2 


□ Coloured  map*/ 
Cartat) 


□ Colouiod  ink  (i.e.  other  than  Mue  or  Maefc)/ 
enera  da  owdaw  (i  A  amn  WW  Maw  M 


Colourod  platM  and/or  illusttatiom/ 
otMnI 


□ 
0 


I  1  Ti#it  Mndmfl  may 


Bound  with  other  material/ 
#1 


or  dIftMlion 
da  Tombra  ou  da  la 


alont  inwrior  margin/ 
la  tent  di  la 
Blank  laam  added  durint  rattoration  may 


□ Blank  laaw 
wilMn  ibo 


been  omitted  from  filming/ 
II  le  peut  que  certainet  pages  blanchas  aiouttet 
lora  d'ww  ratttwalion  apparament  dam  la  laxM, 
mail,  lortque  cela  MWI  PDHiill.  eat  pafW  n'ont 
pat  M  f  ilmtet. 


|~~|ColOMTad 


I — j  Papt  rattorad  and/or  laaabiawr? 
PapM  ditcoloured.  ttainad  or  fa 


Shonvthrough/ 


iiiiawtai)/ 


0 Quality  pf  print  vwiai/ 
QpalMWIplade 


□ 
□ 

□ 

□ 


Title  on  header  taken  froaa:/ 
Le  titw  da  I'en  Itle  prowient! 


Title  page  of  Imiml 
ila 


Caption  of  ittue/ 

Tiwe  da  dtpart  da  la  HvniMn 

Masthead/ 

GMrkiue  (piriodiquet)  de  le  livraiMn 


0 


Additional  eommantt:/ 


Wrinkled  pages  may  film  allghtly  out  of  £ocu8. 
There  are  sone  creases  In  the  alddle  of  the  peg**. 

This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

ge  docMiijent  eit  film*  au  taux  da  rWeatien  indiqu*  ci  dawoui. 


v/ 

m 


2«X 


32X 


L'mwnplair*  fHm4  fut  raproduh  gric*  i  la 


AcadMiy  of  Madtcim  Collaetlon 
The  Toronto  Hotpttal 

Th«  imagM  appaaring  hara  ara  tha  bast  quality 
poaalMa  conaMaring  tha  condition  and  lagHMity 
of  tha  orMnal  eoov  and  In 


tm  aflllt^ 


tha  laat  paga  with  a  . 
•ion.  or  tha  bacit  covar 
ethar  original  eopiaa 


witli  a  pfliMad 


or  illuatratad  imprw* 
whan  appropriata.  AH 
fHmad  beginning  an  tha 
or  illuatratad  inipno> 
withai 


Tha  laat  raeordad  frama  on  aach  microflcha 
ahaN  contain  tha  aymbol  "^Imaanlnt  "CQN- 
TINUB>'^  or  tho  iiwibel  ▼  Iwaawlwi  "BUOI. 


diffarant  reduction  ratios.  Thoaa  too  large  to  bo 
entirely  included  in  one  expoeure  are  fHmad 
beginning  in  the  i^per  left  tani  eomor.  Ml  to 
t  and  top  to  boctont,  aa  many  frotnee  aa 


Academy  of  Hedlcine  Collection 
The  Toronto  Hospital 

Las  images  suiventse  ont  M 
phM  grand  aoin.  aompta  tomi 
dolaneiioiidor< 
conf  ormit4  OMI 
fUmage. 


da  le  eondWoo  ot 


nampleiree  origineux  dont  la  eouvaffuia  en 
pepier  eat  ImprlmAa  sont  fllmte  on  commengom 
per  le  premier  plat  at  an  termlnent  soit  per  la 
demMre  page  qui  eompona  une  empreinte 
dliwpreaaiaw  eo  dIHMeuaUuii.  aett  per  le  aaeond 
plat,  aelon  le  caa.  Toua  lea  autres  oxamplairaa 
orfgifMHui  sont  fUmte  an  commandant  par  la 
premiere  pege  qui  comporte  une  empreinte 
dlmpraaaion  ou  dIHuatration  at  an  terminant  par 

^  ^AmIA^  m,  if  , 


Un  dee  symbolee  suhranta  appareltra  aur  la 
denMre  imege  do  cheque  microfiche,  selon  le 
cee:  le  aynAole  — ^  slgnifle  "A  SUIVRE".  le 

>w  ■ipimi-wir. 


Lee  cortes.  plenches,  tablaeux.  etc..  pauvent  *tre 
filmte  *  dee  taux  da  rMuction  differenta. 
Loraque  le  document  eet  trop  grand  pour  Atre 
(dptodult  an  un  aaid  eMchA»  H  eet  fRmd  A  porthr 
do  I'angia  sup4rieur  geuche.  do  gauche  i  droilo« 
et  do  haut  an  bas,  an  prenem  le  nombre 
d'imeges  nteesseire.  Lea  i 
Uluatram  le  mMiode. 


1 


\  - 


ECTOPIC  gestation; 


is  of  interest  to  the  nedkal  prof  eenon  and  of  value  to  the 
^tgr.  'ha  i^yaaian  ia  aaiiwi  Wvmim  a  dkinoaia  aai  tha  lay 
mmmmmuAmu'lmtiiW^  Ajiwl  iwl  >■■  Uf  mivm 
of  late  on  tiie  aubjeet  and  tiMM  in  anQK  ^MitiaM  ttat  raqaiN 

forther  oooaideration. 
X  Mia  ft  aanM  aMrnh  thioa^  wmar  at  tha  avigiMt  vmm- 

grapln  <m  the  anbjeet  aome  yeara  ago,  aad-ytaggatad-ir^pa^fv  | 
b^(g8^<he^-AB>wQfl»i»-Aaaoaia*io«  of  0bB(atnai<taa  aikU6yii»aela!  / 
giats>ip,lMa-io>ath«^3!^<^-a,j^art-ei«ftJbw.  — i  I  m  n9«( 
able  ht^tre  a  further  reptttt  of  my  ezjseiieaeer^iiS-  app»d~t»  \ 
thia4)aper^t«balat«d  atatentent  ot  tha.eaflea  upQg^^ahieL-it-in 
haCBck — 

All  writers  on  the  subject  are  familiar  with  the  work  of  Dr. 
William  Campbell,  who  was  a  teacher  of  midwifery  in  £din> 
bnri^  who  published  his  monograph  about  18^.  Ha  gave  a 
large  amoont  of  material  with  but  little  attempt  at  good  arrange^ 
ment,  aMq^.5!«ii,  His  work,  however,  is  a  landmark  in  the  litera- 
tnre  of  the  sobject 

On  tibia  aide  ci  the  Atlantic,  Parry,  of  Philadelphia,  published 
a  very  remarioditle  work  on  the  subject  in  1876.  Again,  later, 
the  subject  chosen  for  the  Jenks  Prize  Essay  of  the  C(  Mege  of 
Phyaidaiia  and  SurgMoa,  Philadelphia,  about  the  year  1889,  waa 
^  aSa^fioAi  tM  Mi^BMDt  of  eiLtarwiterine  pregnaney,  and  the 
prize  wa  awarded  to  Joim  Strahan,  of  Bdfaat. 

<saa«  iMiDs*  tfcaAiitmniatHa  eTBilMt  mmmfmm^' 


s 


Tait,  in  1888,  wrote  on  eetopi«  pregnaney  and  pelvie  teMli^ 
Ml*,  nw  woric  ii  b«Md  on  an  vqmkBoe  of  lortgr  OMM. 

SiiiM  tte  tiM  tvta  <iim  wrilia«i  m  ghMB  to  ikt 
•everal  pointa  have  been  noticed:  First,  the  leaa  frequent  mp- 
tnre  of  Mto^  pregqancgr  into  the  br^  Ugameat  thac  wm  np- 
poMd  bgr  VMt  to  Miart  mmd,  Ikt  mm  uttk  iMA  tfct  taail. 
tion  may  be  diagnosed  before  mptnre;  third,  the  freqnenejr  witli 
wkadk  the  diaaue  oeenxi  a  aeoond  time  in  the  aame  patknt  It 

i>at»  my  ri»tohy»t»toi">«»^»«'»^"*»P"*'*»^*» 

<£'  leetnre. 

I  have  a  record  of  45  eaaea  (inelnding  one  caae  of  ruptured 
eramial  imgnuMj)  opmtod  npeo.  they  include  3  eaaea  opow 
ated  on  before  rapture,  41  eaaea  operated  <m  after  mptare, 
1  caae  operated  <m  after  full  time  (raptored  comaal  pregnaiugr), 
5  eaaea  after  aoppnrati«m,  1  caae  of  doable  ectopic  geatation,  8 
eaaea  in  whidi  eetopie  gestation  oectirred  twice  in  the  aame 
patioit,  1  case  of  interatitial  pregnaney  in  ita  very  eariicst  atage. 
I  will  andaavor  to  gW«  ym  tiM  onteot  of  thia  experionee,  not 
embelliahed  in  flowery  langnage,  but  aa  a  simide  atatement  of 
f aeta.  It  will  be  wdl,  however,  to  . .  the  anbjeet  up  ajatemati- 
eafiy. 

OusamcATioN.— The  daatfeatitm  that  I  adopted  in  1892  re- 
^ofaea  no  change.  £et(^  gtatotion  may  be  met  with  in  any 
part  of  Ae  tnbe,  fewa  Ha  intrantwrine  opuiag  to  iti  abdwteal 
end.  When  the  pregnancy  is  developed  in  the  tube  aa  it  paaaes 
1]troa|^  the  wall  of  the  aterna,  we  call  it  interrtitial  or  tobo- 
ittertoa;  if  dtfnlopect  in  the  middle  pcvtion  af  Aa  taba,  tabti; 
if  developed  at  Htm  oiwaton  «ai  at  thatttb^  labo»iWMrilag  m  tofca^ 
abdominaL 

A  pregnancy  originating  aa  an  abdmninal  iwegnaneifAa  not 

been  proved  to  exist.  Tait  says  that  he  cannot  believ#^hat  a 
fertilized  ovam  nuqr  drop  in'-o  the  cavity  of  tite  peritaiieam  and 
haeoBM  davdoped  there,  beeanae  the  powoa  of  digestion  of  die 
poitsaenm  are  so  extraordinary  that  an  ovum,  evra  if  furtilized, 
coald  have  no  chanee  of  development.  If  it  ia  poaaiUa  for  the 
peritoneam  to  digeat  live  atructurea  ao  rapidly,  wkf  do  w  find 
intraperitoneal  worms,  and  how  can  spermatozoa  exist  in  this 
r»>giont  I  have  seen  intraperitoneal  worms  free  in  the  cavity 
of  the perit<«aain in  fiih,  and  I  yraamaa ftat ilia  tlw  aiiatawuM 
of  ttfi    ^  trarm  tint  pravwte -AIb  digeatm.  Ttp  ataaaaaii 


*  MWi  SOMNO  OTRASMI. 


wall  k  only  digeitod  pott  mortem.  I  feel,  mjnelf,  that  tltiMOfli 
■Momlnil  pregnanoy  fxr  m  hai  not  been  dMMUtnted,  thwt  is 
■9  nawi  wbj  it  oumot  oeear. 

A  pregnuMj  oirigiiiatiiig  m  an  ovarian  pregnancy  haa  not  yet 
bean  proifed  to  esiat  Parry  eayi  "that  if  an  ovarian  pi-egnan^y 
doaa  oeenr  it  moat  be  rare  and  win  be  eorioMit  it  never  oeeora, 
•0  xaatk  the  better."  Biaehoff  and  Barry  are  eaid  to  have  dia- 
eorared  ^ermatona  on  the  rarfaee  of  the  vntim  (tf  biteh« 
thortly  after  ooitua.  If  it  is  poariUe  for  the  nirmalniua  to 
penetrate  the  wall  of  the  ovary  and  prodoee  an  ovarian  preg- 
nancy, then,  aa  a  eooBMiiwiMa  of  MMkoffli  and  Barry'a  obaerva- 
Ikma,  avarian  pregnancy  dMBld  be  frequently  met  with. 

Thtie  are  two  etmditiona  that  moat  not  be  eonf  oondod  in  tiie 
el—tff  jatton  of  aetofrfe  geitatioagu  The  lint  of  ttaaa  ia  preg> 
nancy  in  a  bilid  or  bieomuate  ntema,  and  the  seomd  ia  a  pregr 
aano}  ogeorring  in  a  mdimoitary  ntarioe  horn.  llMaa  eon^ 
•Mna  Biiia%  nowever,  m  aoMMefW  u  «t  aiserautsai  '"*gri I'Tti 
of  an  ectopic  geitation. 

Pathoiomcai.  Amatoxt.— After  the  impregnated  ovnm  haa 
beeome  atwalad  in  the  tobe,  a  daddm  avotiBa,  if  net  a  deeidna 
vera,  ia  formed;  the  chorionic  villi  develop.  Thia  devel  pment 
ia  beantifoll;  diown  in  an  early  imj^regtrnted  ntema  of  the  rab- 
Irit  I  have  a  dide  prepared  from  mnA  a  vtnna  vdiite  a  ati^eBt 
in  Zurich.  The  tubal  wall,  into  wld<  h  the  ehorioofe  villi  jmah 
titemeelvea,  beroi  ia  thinned,  and  thia  ia  wdl  diown  in  ma 
of  my  Bpedmoia  oi  nnmptnred  tnbal  pregnancy.  The  speeimen 
had  not  ruptured,  but  was  in  the  ^int  of  rupturing. 

Still  fnrfter  diangea  raw  take  place.  Blood  veaaels  beoomo 
fBHWaaad  in  aiae  aad  ia  manben,  the  parte  heeooM  very  mndi 
ooogeated,  and  the  awelling  of  the  tube,  aa  eeen  nn  aevend  of  tiieae 
apaeimeni,  doady  reaemblea  a  small  myraia  in  in  interior.  A 
deddna  ia  fmased  in  die  intnior  of  the  nteriiM  eavi^;  this  de- 
cidua  forms  early,  but  is  not  likely  to  be  shed  nntil  aftnr  the 
death  of  the  ovnm  takes  place  or  the  tube  haa  ruptured.  I  show 
here  a  qpeeimen  taken  from  a  wcsiian  who  died  at  our  Un'on 
Station  a  few  months  ago.  She  died  from  intraperitoneal  henKN^ 
rhage  that  was  produced  by  mptare  of  a  tube  containing  an 
ectopic  gestati(m.  Even  though  the  pregnancy  was  of  short 
-duration,  ^  deddual  lining  can  be  distinctly  seen. 

A  tdml  i^^BaaoT^  ia  ficefoaufly  inisredbir 


4 


mm  TiMtlij  Uood  ii  ihm  ponnd  oat  •round  the  ovtua  into  tho 
teHtioroCtbotiibc  Tho  pNftM  of  tho  oonditlMi  mv  dipMdi 
teply  upon  the  aite  occupied  by  the  imprognatod  ovum.  Hm 
ipol  in  whieh  ewlMrt  rupture  take*  pUoe  k  oMur  to,  or  in,  tiM 
rtlgfaw  wmU  whMC  t>»  tabo  piwm  tfct  himwIw  ■twwtewi  of 
tth  organ.  The  middle  portimi  of  the  tube  allowi  of  mneh 
giwitr  dirtwHti'Wj  and,  m  •  eontoqawMii,  tho  pregnancy  in  thk 
jHuiUih.  win  muMwl  ftilfcw  >miMil  nptifi  VkwtlMonuB 
k  lilMliA  tMMid  liM  abdeiriMl        of  Ikt  tab%  abi^ 


Vm.  li—A,  niptwtd  tnlwl  prafsaaqr ;  B,  deetdiui  in  (Mm. 


tioB  is  Uriilo  to  OMBr  throBgh  the  fimbriated  end.  mda  kdc  SHgr 

only  be  small,  or,  in  other  words,  a  tubal  "drip." 

Bupture  of  the  sac  may  occur  at  any  of  the  sites  liable  to  be 
occulted  by  the  impregnated  orum,  and  the  result  may  or  bmj 
not  be  i$M  to  Htm  notlitf  nd  nasf  at  majr  not  bo  &td  to  Hit 
fetua. 

Tlw  oiram  amnrtres  the  mptore  in  only  a  very  few  eoaea.  Tha 

site  of  rupture  in  the  interstitial  variety  may  be  so  small  as  al- 
most to  escape  detection,  as  is  shown  in  the  specimen  here  ex- 
hibited (Ilg.  2)  and  rqwrted  in  tbe  taMo  aa  Ko.  M. 

Tait  says  that  rupture  may  occur  as  early  as  the  fourth  week. 
I  think  I  have  aeen  it  oeeor  eaiiier.  ,  In  Thb  Amwocam  Joubkal 


worn  I  MTono  owrAiMM. 


i 


or  OBSTmiicB,  October,  18f  >.  one  of  my  eun  w  recorded  that 
nip.tiped  at  •  vciy  rrly  st  ,  ge— I  tlioai^t  aboat  two>  or  thm> 
wcaks  iMtatkM.  ▲  iiistr  m  Hmm  fffwi^  Amhi  fecai  — tm, 
but  tbc  plate  does  not  exactly  repreamt  tbe  aixe  of  tha  tuba  at 
tba  ntarine  end.  It  waa  nnaUar  tbao  it  ia  tbm  npn  aatai  vaA 
aoffwqwuded  more  mtaif  arMi  tta  cMidMea  of  Urn  taMNil  tto 
distal  lidu  of  the  rapture. 

Tha  bleeding  fr<Hn  an  ectopic  geataticm  nay  ba  either  kitr»> 
portaMri  or  oitnNparilaaeol.  htwyoritaaeri  hwwrrhmaaMy 
occnr  in  two  wajrts  fint,  by  direct  mptnre  of  the  tube  into  the 
paritoneal  asvtty;  atoand,  by  the  tubal  drip  or  a  leakage  drop 


Fia  2.— Intmtlttal  prcgaaaey,  tot  mOg  t«tw*  (Can  SM.   A.  (Mt  at 

^ieb  ntcrint  w«ii  was        to  9m!tm^mmmK»mi  ^  *mmm 'miiii»  •* 


bgr  drop,  of  blood  throogh  tiie  fhribrteted  00**  of  the  tite.  Vthm 
extraperitoneal  it  becomes  so  as  a  couaequence  of  rapture 
through  the  mesoulpinx  into  the  l^ren  of  the  looad  ligaiMnt. 
A  great  deal  of  streai  haa  been  laid  upon  this  lattor  font  <rf  rup- 
ture, but  in  my  experience  I  have  not  met  with  it 

In  the  table  it  may  be  noted  that  I  found  diatenaioB  of  tha 
bMMid  Ugament  on  a  certain  nda  after  opening  the  abdoiueB,  hot 
that  the  sac  waa  peeled  out  aa  the  operation  proceeded.  Had  the 
rapture  been  into  the  layera  of  tiie  broad  ligament  it  woi<diJ|Mf«  . 
bten  impoasiUa  to  have  peeled  out  the  MC  in  this  way. 

On  superficial  examination  many  of  these  <i8es  will  simulate 
%  mm  in  tiM  tooad  UgaBMfit,       aa  Oflse  t^ftta  do  that  iMM 


fMmsrIy  reeordfld,  and  llMt  m  perhaps  itm  nemrded,  by  tbe  in- 

qrati.  The  qnta  referred  to 
are  now  known  to  be  un- 
der tiw  broad  lifanmt— 
anbliCHBentoiiB  and  not 
irtraHiaiiMfntoaa  Thqr 
«aabei«iiilrJBttiBgaiah- 
ed  owing  to  the  f  aet  that 
the  tube  will  be  found 


per  Btirfaee.  On  closer 
inq>eeti(Hi  thegr  will  be 
foBBd  dodbM  vadar  ^ 
ligament,  but  intimatdsr 
aaaoeiated  with  it  I  do 
not  for  on*  OKment  deny 
that  hmorrhage  into  the 
broad  ligament  does  not 
oeetir,  bat  I  nrait  idtfit 
that  very  few  of  theaer 
cases  are  brought  to  the 
operating  table. 

I  take  it  that  the  bleed- 
ing tnm  an  extrauterine 
pregnnqr  auqr  be  either 
slow  or  n^id.  When 
slow  the  blood  coagulates; 
when  rapid  it  does  not 
eoagnlate  to  nieh  an  «s- 
tent  When  tiw  blood 
eoagtdates  it  produces  a 
noMs;  when  it  does  not 
eoagnlate  no  todi  bum  fa 
produced.  When  the 
hemorrhage  ia  slow  and 

■9A  Mliftll  flOAffDlSltfiB  flu* 

hMatm  are  rapidly  form- 
ed ■MBBd  the  site  of  tiw 
kmorfhaga,  ntd  in  ft 
short  time  just  as  mueh 
tenaioD  will  be  prodneed  in  this  way  aa  ean  be  tmtad  by  the  fatoia 
layers  of  the  broad  ligament.  Aftw  a  tfane  tito  ■aaooat  of  btood 


BOM:  ECTOPIC  OIBTATIOH. 


T 


irill  bt  iacnaaad  bgr  lr«i^  ktBurriugt  and  tha  tdhcnoM  will  no 
lBBgtrb»«M>tetetifatfc»aMMi,»nd,M»BaBMq«wiiwi,fa<»W>dl 

wiU  be  poared  into  the  peritoneal  cavity,  and,  if  in  any  large 
qoaatilgr,  will  ba  found  aahii^  op  aatibe  liver  and  Hileen.  Wkm 
flw  Weed  Iowa  ibwIytiwpaUeMliliiwtttodaafiynaape  and  <>f 

pain,  and  if  the  hemorrhage  ceaaes  for  a  time  they  resume  ap- 
pamt  good  haaUh.  The  maaa  otmtinQea  to  inereaae  in  tba  pd- 
▼ia  as  bof  aa  Hm  keauntega  a— tinmi  intonrittaMtty. 

In  support  of  his  argument  in  favor  of  broad-ligameBt  np* 
tax*,  Tait  aaya  that  peritmiitia  nuraly  ocenra  in  eaaea  of  twd 
HgnMRt  mptam  aad  that  the  talk  aboat  eoUaetkna  of  Mood 

becoming  encysted  is  tiie  veriest  nonsense.  I  beg  to  assert  that 
the  blood  doea  baoome  encysted  and  that  I  have  removed  such  «n- 
flTitad  Uood  maiqr  tu<Ma.  It  is  not  difBenlt  to  ondMatrnd  hafw 
we  nuiy  have  the  organization  of  this  blood  dot  without  an  ap- 
predable  amount  of  inflammation.  Such  organization  of  the 
UOfld  is  BSl  ft  Ssaolt  of  inflammation.  Campbell  recognized  this 
feature  years  ago,  and  said  in  his  book  that  the  connection  with 
the  original  mass— meaning  the  poured-out  blood— through  time, 
with  the  adjacent  parta  baeowea  ao  intimate  that,  when  super- 
ficially considered,  the  ovum  majr  aoem  to  be  invd^Tid  bgr  the 
layers  of  the  broad  ligament. 

Tait  considers  that,  in  many  cases  after  other  operationa  upon 
the  tubea,  tha  maaa  Oat  oeeaaioaally  forma  ia  an  intialiganait- 
ous  hoauttooela.  There  baa  been  no  proof  adduced  that  Hmm 
BMMM  ai«  intraligamentous  hematoceles.  Sec(mdary  hemor- 
rittfa  fa  a  wall^recognized  occurrenea  after  tba  ligi^ora  ol  tha 
blood  ▼eaaeli  in  other  parta  of  the  body,  «Dd  amang  Hum  ttkMi, 
dense,  and  edematous  structures  in  the  pelvis  there  is  no  reason 
why  secondary  hemorrhage  should  not  also  occur.  When  these 
bamriliagea  do  oeear  it  ia  difknlt  to  nMbmtaBd  wlqr  ttey  AevM 
select  the  layers  of  the  broad  ligament  instead  of  the  pelvic  cavity 
itself.  I  am  satisfied  that  oozing  may  take  place  from  the  atump- 
of  an  amputated  ovary  and  tabe  faito  Hte  gamnd  paxitonaal 
cavity  among  the  intestines,  and  that  this  oozing  may  cease  and 
the  blood  clot  may  be  absorbed  or  require  vaginal  section  tot  ita 
raaoival  (m  ia  a  mm  of  Dr.  E.  O'Baffly,  of  BntftoB). 

Tait  says  in  his  "Lectures,"  on  page  37:  "Thua  I  tied  the 
pidide  of  one  ovarian  tumor  with  catgut  and  the  patioit  died 
m  tiN  Um&L  day  after  opwatioa.  I  UmaA  a  Ihv»  la/smfmA- 
tfnil  hematocele,  due  to  the  gestation  and  loosening  of  the  liga- 
tara."  He  atatea  that  these  hematooelea  produced  by  ruptore 


8 


B08B:  ICTOPIO  OEBTATION. 


into  the  broad  ligament  pradoM  itrietiire  ot  the  netani;  and  in 
leoording  nidi  a  eaae,  tiie  taty  eridenee  tiiat  be  bringa  to  bear 

to  prove  that  the  effusion  of  blood  was  in  the  left  broad  ligament 
is  the  faet  that  the  floor  and  the  posterior  wall  of  the  abseess 
wwe  fbond  to  eowstot  9t  tki  lawiiiiated  Uood  dot.  £d  Ui  seal 

to  establish  the  new  theory  he  goes  so  far  as  to  state  that  effusion 
of  blood  into  the  broad  ligament  may  be  prodneed  by  a  sadden 
arrest  of  menstmaticHi,  aac^  farther,  tilwt  uuiBlwa  df  eaaea  in 

which  this  effosion  occurs  do  not  think  it  worth  while  to  ask  for 
medieal  assistanee  and  get  quite  well  without  it  "And,  atiU 
forfter,"  Tait  aiya,  fai  dlaeuwiag  a  eaa^  that  waa  ■awx*'^  t» 

one  of  ovarian  pregnancy,  reported  by  Hildebrand,  "the  very 
fact  that  it  was  discharged  by  the  rectum  is  conclusive  evidenoe 
that  it  rested  in  tlM  bXNid  UgUMSl." 

Such  is  the  argument  he  uses  to  prove  his  case.  Do  not  ab- 
scess of  the  ovary  and  abscess  of  the  tube  burst  into  the  rectum 
without  going  throo^  the  diverse  channel  of  the  broad  liga- 
ment f  I  have  reported  one  case,  in  the  Transactions  of  the 
Michigan  State  Medical  Society,  1892,  of  secondary  suppuration 
of  an  ectopic  gestation  that  ruptured  directly  into  the  abdominal 
cavity  itself,  and  I  feel  satisfied  that  these  intraperitoneal  hemor- 
rhages, producing  organized  masses,  may  rupture  either  into  the 
rectum,  bladder,  or  abdominal  cavity  at  will,  and  tiiat  they  are 
not  inflneneed  in  any  way  by  the  preaaeew  ahamea  of  the  broad 
ligammt. 

If  the  fetus  dies  and  the  placental  structures  become  inactive, 
recovery  may  occur  whether  the  hemorrhage  has  hem  into  the 
layers  of  the  broad  ligament  or  into  the  poritonad  eavity,  as  a 
consequence  of  absorption  of  the  masses.  If  the  placenta  re- 
mains active,  a  further  hemorrhage  either  into  the  broad  lig»> 
ment  or  into  tite  pelvic  cavity  may  occur  and  serious  and  dan- 
gerous symptoms  may  supervene.  Or,  further,  suppuratioa  may 
take  place  with  the  formation  of  a  pelvic  abscess. 

If  fBtea  lives  H  »^  develop  in  tiie  abdomteal  otvity,  in 
the  layers  of  the  broad  ligament,  and— but  very  rarely— in  the 
tube  itaelf .  When  it  develops  in  the  abdominal  cavity  the  fetus 
is  really  surrounded  by  amaitm,  tho&g^  it  mtj  be  difflenh  to 
make  it  out.  In  one  case  on  which  I  operated  the  fetus  hi^ 
escaped  from  a  bicomuate  uterus  that  had  ruptured.  The  preg^ 
nancy  readied  full  time  and  a  secondary  rapture  of  ^e  sac  oe- 
curred  at  the  end  of  the  ninth  month.  Primary  rupture  did  not 
ntlce  place  into  the  brutd  ligament  The  »ic  surrounding  the 


MM;  BCTOnO  OBRATICnf. 


f 


ftHm  wof^  eisily  have  been  BiiMaken  for  broad  ligament  at  the 
tinw  ot  eptatioB.  Hm  plaiecBte  after  rapton  aMgr  ranain 
tnthin  the  omui  geetation  sac,  or  it  may  be  partially  extruded 
and,  with  the  eontimanee  of  it»  growth,  may  epread  out  over  the 
B^l^hAori]^  viaetia. 

When  tnbal  abortion  oeenta  Oe  pkwwta  is  of  conree  extruded 
into  the'abdominal  cavity',  and  under  mdt  oircumstanees  it  seema 
h$mBf  pvolNiila  that  it  ean  have  any  power  of  taking  oa  new 
adhesions  to  continue  its  life.  If  the  placenta  remains  entire 
within  the  gestation  sac  after  the  extrusion  of  the  fetus,  there 
will  then  be  two  laes,  one  containing  the  fetoa  and  tha  othw  tlw 
placenta,  and  the  cord  will  pav  through  M  epeoing  eommini- 
cating  from  the  one  to  the  other. 

Saa  OF  THE  Rabeb  CoNDinoNa.— /utrnMioI  pregnancy  is 
tat  nurdy  met  with.  Ihavemet  withitiBOoeeaa^of  whidithe 
following  is  a  report:  Mrs.  S.  (No.  3i  in  table).  Patfaotofl^. 
'fyftaoM,  of  Toronto.  She  had  missed  one  period;  had  sli|^t 
hemonhafe  from  the  uterus.  Bef on  the  doctor  saw  her  ah^ 
had  fainted  three  or  four  tisMa.  Had  been  t^t  ill  at  boob 
on  .the  previous  day  with  sudden,  severe  pain  in  the  abdomen. 
She  vraa  sent  into  the  hospital  under  my  eare,  and  the  case  was, 
nnfortnnatdy,  not  eorrectly  diagnoaed  by  tiia  luoie  largeQa;,  M 
he  thought  the  patient  was  threatened  with  a  miscarriage.  In 
the  morning,  when  I  saw  her,  she  waa  almost  moribund.  Oper- 
ated, hsmtnr,  and  tomA  the  abdiuaiiBal  eavity  fnll  <si  Ueod. 
It  waa  very  difficult  to  make  out  the  point  from  wfakii  the  hemor- 
ibage  waa  e(»ning.  Drew  up  one  tube,  found  it  healthy;  drew 
up  the  ot^  tube,  f<»iiKl  it  healthy,  anl  waa  lor  a  BHnent  at  a 
loss  to  know  what  to  do.  On  raising  the  uterus  I  found  a  small 
spot  on  its  anterior  wall  behind  the  junction  of  the  round  liga- 
meirt  iritt  Ibo  ttterisa  faadna.  On  sp<mging  this  off  I  eod& 
make  out  distinctly  a  small  cavity  about  the  size  of  a  small  pea, 
with  dark  edges,  and  from  which  blood  oozed.  It  was  evidently 
a  nqptnre  of  an  interstitial  preipaaflgr  of  but  very  short  duration. 
The  patient  died  the  same  afteniooB  and  I  have  hare  *hA  J)§§!§p 
men  to  show  you  (see  Fig.  2). 

Intaia^ial  or  tubo-uterine  pregnancy  may,  however,  contima 
to  grow  for  several  weeks,  up  to  ^e  end  of  the  fourth  month,  or 
even  longer.  Buptore  may  take  place  either  downward  into  the 
cavity  of  the  uterus  or  upward  into  the  abdomen.  We  have  no 
positive  evidence  that  a  downward  JlBlWO  has  ever  taken  place 
without  eoineident  ruptnre  into  tht^lliilMB,  bat  nqttnre  into 


10 


mom:  tct<ma  gibtatiok. 


the  abdomen  slone  has  been  met  wttii.  Yergr  nvm  ^maanha^ 
is  one  t9ie  nuun  features  of  tins  fom  of  e&tiaiitariiM  ptt^ 
imiqr.  Tiqrior  met  iri^  but  one  ease  in  his  secies  of  4Z,  Law- 
son  Tait  met  witii  bnt  one  ease  in  Ma  asnai  «f  lit,  «ad  I  «Nt  irMl 

bnt  one  ease  in  a  series  of  45. 

Intra-  and  Extrauterine  Pregnancy.— Tf^f  friend  Dr.  Stn^, 
of  our  ettgr,  has  net  wifli  mA  a  easa.  He  has  kiadly  tuoMmA 
me  with  the  follcnring  notes:  The  pwtf«it% Hial  <MM  rnmlmm 

after  an  ordinary  labor  of  a  few  honrs.  Another  ehild  wm  then 
felttobeintiwaibdocidbdMmty.  It  eoold  be  eaaily  aadia  ««t 
and  the  fMal  hMi^  aonnda  <BewM  bo  Iwttd.  IRs  aMtoHMi  WMi 

not  opened  until  the  following  day,  when  the  ohJd  was  reMWai 
without  trouble.  The  placenta  was  foond  sttariad  iiMUlllll| 
Over  "thfe  psoas  nnisele  vsA  ina  oot  Wms^^afl.  fiMsMtriH^t 

gan  at  the  time  of  the  operation  and  could  notba  efllitwllti,  Mli 
the  patient  died  four  oe  five  hours  after. 

ail  oWorwirta  eflfipkwfasa  ^tte  ftot  Aat  ft  is  •rtwiHafy 

dangerous  to  operate  during  the  life  of  the  fetus. 

Doutle  Extrauterine  Pregnancy.— I  have  met  with  oat  «aae 
ttf  dtiUMa  mntuteriM  preguauey,  of  wtMi  fha  fdknniig  w  ii 
report:  Mrs.  E.  (No.  42  in  table).  Patient  of  Dr.  Andrew 
Eadie.  Wn  taken  ill  one  .<igfat  with  sudden,  severe  fainting 
i^dli  whib  ^g  in  bed.  Wub  not  seen  by  Dr.  Bii^  tailB  flw 
morning,  when,  on  examination,  he  found  a  large  mass  in  the 
pelvis  behind  and  to  the  eft  of  the  uterus.  I  saw  her  at  <mee 
and  from  her  appearance  judged  that  the  case  was  one  of  rup- 
tured ectopic  gestation.  She  had  the  peeulir  r'  o(doring  of  the 
skin  so  frequently  noticed  and  a  e<^psed  appearance.  On 
fnrfiier  inquiry  it  was  found  that  in  Av^gvmt  she  had  men- 
struated. In  September  she  had  seen  very,  vwy  little;  m 
Oetober  again  but  little  was  seen.  Some  pieoea  of  deeidaa  had 
come  away  from  the  uterus,  but  ttey  were  not  pteaerved.  The 
br«»ts  indicated  pregnucy.  On  auauaatkn,  lettaA  Uood  elot, 
breakii^  down  under  the  finger.  Was  Mtfafied4iMrt1iM«Hfti»aB 
one  of  ruptured  extrauterine  pregnancy. 

On  November  1, 1901,  in  the  Toronto  €l«T>eral  Hoqtital  Ftttvfl- 
ion,  aaaisted  by  Dr.  Eadie,  I  opened  the  cbdoBMB  Ib  Om  awAan 
line  and  found  the  abdcnmnal  cavity  full  of  blood,  ^passing 
the  fingers  down  to  the  right  side,  found  a  smidl  raaii;  Mi  dr«w- 
fa^C  itiB  vp,  fistnid  ft  "to  %0  ouautom  with  ha  wtopio'garia^  " 
iMteder  its  folds,  running  up  to  the  surrounded  Fallopian  tube. 
^  removing  tiiiis  sac  the  FBllopi;< '.  tube  was  torn  off;  ovary  tad 


ti**  Ml  tiiit  ode  were  lifted  with  silk.  As  worn  m  fwta- 
Ite  Mi  distvrbtd  a  gr«at  deal  of  fresh  blood  wm  pound 
•■1  n»ifliM>tiK»llien  pMMd  dowB  t  tlM  otbar  side  at  a 
matter  of  routine,  and  to  my  surprise  I  found  aaoOier  g«atatiff» 
•M  eoBMOtsd  witii  tke  left  tnbo.  This  waa  rapidly  ranovad 
htm  Urn  adhaMM,  and  on  its  ranoval  it  btust  and  tha  lienor 
amnii  escaped,  together  with  a  three-and-ona-bali^MMitfaa  fotaa. 
The  two  gcoUtimi  saoa  were,  tharef««,  of  dilEnrsnt  agea,  and 
the  right  <Mie,  thoii<(h  analler,  was  eertainly  actiTe  as  well  as  the 
left.  Tha  padiilA  waa  than  tiad  off  oatiMlaftsida,  a  portion  of 


Vts.  *.—Cam  42.  SoaH*  mn  pNgMwe/.  A,  flfM  m»,  aisM  mmn  a, 

the  ovaiy  bang  left  to  continue  meustruation.  Abdominal 
cavity  was  washed  out  rapidly  and  the  patient  alzuost  sank  on 
tha  tabla.  Snbentaneoos  inje«tiia»  of  sidisfla  were  'ven  under 
the  breasts,  the  arms  and  legs  bandaged,  a  drainage  t  '.be  was 
plaoed,  and  the  wound  dosed  with  ailkwonn  gat  The  pa- 
tient devstoped  plauriqr  with  *Mmim.  into  the  1^  ehc^  l»Ha 
which  I  ranoved  twenty-eight  ounces;  inH,  aotn^MwiihBg  this 
f  net,  she  made  an  excellent  recovery. 

Tlia  fast  that  both  sidia  wars  active  proved  to  ne  that  it  ia 
quite  po  ible  to  have  pregnancy  occur  in  one  tube  and  then,  at  a 
subsequ«ut  date,  occur  in  the  opposita  tube  while  the  £Lrat  is  still 


12 


KMB:  XCTOPIO  eCSTATION. 


developintr.  The  pngmney  in  one  tube,  in  this  eaM,  wm  evi- 
dently of  three  and  one-half  nonlhs'  dnntion,  while  tt*  preg- 
nancy on  oter  iiia^  we  jviiBd,  was  of  *byat  two  noBfti' 
doratioii^ 

Ket^pie  Bntation  Oetmrrktg  Twie«  im  Ifte  8mm  Mjenl.— Ify 

experience  with  caaea  oeeoning  t^riee  in  the  aoM  pstiflBt  ii  m 
foUowa  (three  eaaea): 

Cjm  i.—1tn.  H.,  «t  21  (Ho,  8  is  tiMe).  Operatod  ob  Jidjr 
6, 1891.  Had  no  children,  but  ttm^lht  ted  wiacarried.  Had 
paaaed  three  weeks  over  her  xomiti^fPoM^  aad  had  beoome  on- 
mil  and  reBidiied  so  for  seren  wedn.  The  ftowing  then  eeased 
aad  eonunenced  again  two  or  three  weeks  after.  Severe  pains, 
like  labor  pains,  appeared ;  she  became  eoUapsed.  The  collapse 
disqipeared  and  on  Jane  90  she  walked  to  tite  hosf^tal.  On  ex- 
aminatitni  a  mass  was  found  in  front  and  to  the  right  side  of  the 
utorns.  Betnming,  two  days  later,  to  the  hospital,  I  operated 
aod  iMrad  the  abdomoi  f&ed  with  old  datk  liqnid,  and  not 
clotted,  blood.  The  woman  had  evidently  been  going  around 
with  this  blood  in  her  abdominal  cavity.  Removed  ectopic  gesta- 
tion from  the  "ight  side. 

(Table,  No.  9.)  On  October  10,  1895,  I  saw  her  again  with 
Dr.  Noble.  Found  her  collapsed,  pale,  with  all  the  appearance 
9t  ia^bumi.  iKmorrhage;  precordial  uneasiness.  Patient  locked 
andoos  and  very  ill.  She  had  gone  two  weeks  past  her  period. 
A  siriden  pain  eame  on  shortly  after  she  wakened  in  the  morn- 
ing. No  elevation  of  temperature.  A  mass  was  felt  in  the  cul- 
deeae  of  Doui^  and  broke  down  under  the  examining  finger. 
Removed  an  extrauterine  pregntmcy  frran  tin  lett  side.  Pati^ 
recovered.  This  case  was  reported  in  Thb  AniOiir  iovwHJJj. 
or  Obstetbicb,  Febmary,  1896. 

Cjub  n.— Mm.  h.,  et.  S6  (table,  No.  14).  Referred  by  Dr. 
IfcMahon.  Was  nursing  child  17  months  old.  Did  not  miss  a 
mcmthly  period.  Was  quite  regular  until  she  began,  after  one 
poriod,  to  1km  eoBtinoonsly.  I^is  eontfmied  for  fonr  weeks. 
Patient  was  sent  to  my  office,  and  I  found  the  left  tube  and  ovary 
normal,  right  ovary  normal,  right  tube  enlarged  at  its  outer  end 
and  lyhig  in  £nmt  of  the  uterus.  Two  di^s  after  (August  14, 
1896)  I  removed  an  extrauterine  pregnancy,  unruptured,  from 
right  tube.  Though  the  tube  was  unruptured,  the  abdomen 
contained  <M  Uood,  nd  hfood  eoold  be  seen  to  ooae  from  the 
fimbriated  end  of  the  tube  when  it  was  dnom  ^tap  hjr  dse^ 
coming  very  slowly  (tubal  drip). 


On  Ctptmber  88, 1898  (teble,  Ma  27)  law  tlM  patknt  again 
wHhi.  .iBadfo;  Had  bImmI  a  oMBfUjr  p«M  and  goM  a  f^f 

dsys  over.  Irr<sgalar  hemorrhage  from  the  utenu  and  cramp-like 
paina  in  tba  lower  part  U  the  abdomen  and  ebiefly  <»:  the  left 
■Mt.  91w««vfl9rf«i8m  wkfrfeaiaiMier 

again  and  found  a  man  to  the  left  side  and  behind  the  utenu.  I 
ezamiiied  her  and  found  the  ovarjr  to  oe  <doae  to  the  uterui  and 
Mnnat  In  dm.  Nest  day  TtmamA  aa  Mrtnraterine  pregnaney 

from  the  left  inbe.  The  ovary  formed  a  cysi  that  had  evidently 
been  taken  for  the  geatation  sac,  and  the  gebtation  sac  had  been 
lakni  fwthaovaiy,  being  hard  and  firm  and  unruptured.  The 
ehorionic  villi  were  pcTictTiiting  the  tube  wall,  and  the  wall  mi|^t 
have  ruptured  any  moment.  There  wan  no  blood  present  in  the 
abdominal  eavity.  There  was  no  etv'denee  of  ligature  or  stump 
of  tube  on  the  opposite  side,  removed  two  years  bef<Hre.  The  wall 
of  the  uterus  was  smooth  from  the  fundus  downward.  Paliest 
recovered.  This  was  reported  in  Ths  American  Joubnal  of 
OMTimucs,  volume  zxxviii,  No.  6,  with  the  names  of  the  attend- 
ing physicians. 

Case  in.— Mrs.  R.  (table,  No.  20).  This  case  has  not  been 
previously  reported.  Her  physidan  was  Dr.  Fletcher,  of  Enelid 
avenue,  Toronto.  She  had  not  missed  a  period,  but  uterine  hem- 
orrhage came  on  and  etmtinned  for  tfat  ^e  weeks.  She  then  had  a 
sudden  attaek  of  f aintaeas  uA  beeaioe  bathed  in  por^iratioo. 
Had  paina  of  irregular  eharaeter  in  the  htwwr  abdomoi.  On  ez- 
amination  a  mass  was  found  beh<  id  the  uterus. 

On  January  14, 1898,  dielle .  -at  an  eeb^ie-geptatioo  soe  with 
tiMdotsfoundrabaequatttoiaptore.  Left  tube  and  ovaiywm 
incorporated  in  the  mass  and  were  removed.   Patient  recovered. 

(TaUe,  No.  88.)  In  June,  1901,  saw  the  patient  agun  with 
Br.  Refedwr.  Sla  bad  tedeinite  pelvic  paina  and  bad  wm  hmA 
on  account  of  these,  as  we  had  advised  her.  On  careful  exami- 
natifm  the  doctor  found  a  little  nodule,  he  thought,  on  the  right 
tabe.  I  examined  and  taanA  tiw  «me.  ^e  patient  had  a 
iHl^t  flow  of  blood  from  the  uterus.  We  sint  her  to  her  home  in 
the  country  and  advised  her  to  return  in  two  weeks.  She  did  so, 
and  we  examined  her  again  and  found  the  maas  had  ineMcaed  to 
double  its  size,  and  concluded  um  mm  m»  9t  tat/bna^Mkm 
pregnancy  on  the  other  side. 

On  JmM  21, 1901, 1  opened  fbe  abdomen  and  fuund  a  bema>> 
taam  of  the  right  ovary;  drew  up  the  right  tube  and  found  an 
mlbagie  gestation  the  sixe  of  the  aid  of  the  little  flng».  It  was 


14 


MM:  BUTOPIC  snTATicnr. 


the  MtfUMt  imniptiired  eetoj^o  gartatte  I  ksvt  mr  imb.  B*> 
moved  tobe  and  omy  on  tiut  aide. 

When  making  njr  flnt  report  of  Caae  1,  in  which  ectopiv  geata' 
tioD  eeeamd  twiee  ia  the  mhb*  pati«it>  I  hwhed  m>  the  litara- 
tnre  of  the  eiAJeet  cod  fevttd  hot  five  itetkur  lapofflatiHrt  entbfeljr 
satiBfled  me  as  to  the  correctness  of  the  diagneaia  in  each  ease. 
It  cannot  be  poeaible,  however,  that  I  have  had  an  ese^pli«mal 
eaperieaee  in  HHk  rmptek  Ttgior  aaja  that  vpwaid  of  fif^  aodi 
cases  have  been  re^rded.  In  his  own  case  I  find,  however,  that 
the  fiiat  ectopic  ge^tion  waa  not  demonatrated  by  aorgieal  apW' 
aticB  or  pertaaerfgai  tiwlnation,  tad,  in  view  of  idttk  I  h«rt  to 
relate  later  regarding  conditions  that  simnlate  mptared  eztra- 
vtnine  pregnancy,  I  am  not  pr^red  to  accept  rqwrta  without 
aadi  aargieal  w  peatei'Tfliai  verifleatioai.  b  sgr  eaaaa  Ike  fseih 
nan^  oeeorred  fltat  <«  the  <«e  nde  and  than  ea  tiM  ether. 


ViQ.  5.— V«i7  •Ml;  aaraptortd  tvtisl  pNgaaacy  at  A  (Cm  88). 

Coe  has  reported  a  case  in  which  a  lithopedion  was  found  on 
the  same  side  as  that  on  which  the  ectopic  gestation  'vaa  situated 
at^timeof  operatioB.  TluadanoartratedtbefaettSurteet^pie 
gestation  can  occur  twice  on  the  same  side. 

Ectopic  Geatation  FoUowed  by  Conditions  Simulating  Ectopie 
Oe$t9tion  and  Requiring  Operation.  Cabs  I.— In  the  table  t -'is 
case  is  reported  as  No.  1.  Was  operated  on  for  extrautenae 
pregnant^  December  24,  1886.  She  had  good  health  and  bore 
ene  ehild.  Betianed  «gain  and  was  epncatad  on  Peaamber  10« 
ISSdf  and  a  hematosalpinx,  the  blood  of  which  was  uncoogulated, 
was  removed  from  the  other  side.  There  was  no  evidence  to  indi- 
01^  ttat^ftia  waa  the  wanh  of  impregnation.  The  uTurtrwi  on 
the  second  occasion  were  a  contii>ucd  Sow  fres  ^  stKOS  to- 
gether with  a  mass  on  the  left  side. 


MM:  KTono  OMiAnair. 


1ft 


Cam  XL— This  caw  k  recorded  in  Um  table  m  No.  32.  Oper* 

turned  on  April  24, 1902,  and  was  operated  on  April  26,  when  a 
tiib<H>varian  cyat  on  the  left  side  was  removed.  She  eomphuned, 
on  the  second  occaaion,  of  pains  in  the  lAdomm,  ehkflj  OB  tht 
left  side.  Had  missed  one  week,  but  had  no  nterina  IrniMlffrlnail 
The  mass  conld  be  felt  on  physical  examination. 

Casi  UL— CaM  Mo.  13  in  the  table  was  operated  on  for  eztra- 
oterina  ymspanqr  Seeember  24,  1895.  She  returned  again  and 
«M  opwatad  en  Oetebar  19, 1^,  for  a  hydrosalpinx  on  the  left 
aide. 

Gam  IY.— This  ease  is  reported  in  the  table  as  No.  17.  Oper- 
ated oa  ior  extrauterine  pregnancy  on  July  13,  1897,  when  the 
right  tube  and  ovary  were  reiioved,  U^tether  with  gestation  sM 
on  that  aide.  Left  tube  and  o^tay  looked  beaUby.  She  re- 
turned again  <m  Mareh  25. 1898,  and  at  the  operatkm  I  lemoved 
a  hcmatoealpinx  un  the  left  side. 

Cases  of  Previous  Operation  for  Othtr  Conditions,  FoUowtd 
by  Eetopie  Otstatum.  Csn  Mia.  MeC.  (No.  22  in  tabte). 
In  o  ily,  1897, 1  removed  a  small  cyst  of  the  ri|^t  ovary.  Patient 
made  an  uninterrupted  recovery.  In  Febm&iy,  1898,  removed 
eetopk  gertatum  after  rupture  <rf  the  see  or  tin  left  rida. 

CaSb  II.— Mrs.  B.  (No.  44  in  table).  W  perated  on  May  4, 
1890,  for  large  ovarian  tumor.  Seeondary  hemorrhafe  ooeocrod 
«Bd  the  paiiMt  was  reqmied  A»  aam  dajr.  Baeorered  iiiA 
some  inflammatory  symptoms.  On  January  28,  1902,  operated 
&^ain  and  removed  an  extrauterine  pregnaney  a£ter  mptuxa  of 
^  aa^  f^  the  <^posite  side. 

The  experience  with  these  cases  gm  to  i^e  that  ectopic 
gestation  follows  the  woman  who  has  once  hst*  it  pelvic  inflammj- 
tion.  The  report  shows  how  diffioilt  it  ia  ta>  be  ewtam  that  a 
condition  givifl^  enrtamigni^taiM  ia  mdoidrtatBir  mlm^  tf^ 
tion. 

I  operated  on  the  wife  of  one  of  our  leading  pnetitioBWB  for  a 
ruptured  ectopic  gestation.  She  subsequently  became  pregnant 
and  bore  a  living  chi](l,  but  in  the  interval,  before  pregnaney  oc- 
curred, she  was  suddenly  seized  with  all  the  apaptana-flf  a^mp> 
tured  ectopic  gestation.  No  surgical  operation  was  performed 
and  she  made  a  good  recover^'.  Can  I  state,  in  such  a  case,  that 
the  patient  undoubtedly  suffered  from  extrauterine  pregnane 
on  two  diJiterent  oc^sionfi?  I  have  refrained  from  including 
thia  eaae  in  my  table  of  ectopic  gestation  occurring  twice  in  the 


If 


ROM:  CCTOnC  GOTATlOir. 


same  patkot,  owing  to  the  anetrtmiatj  that  tzkted,  but  I  flad 
that  there  bave  been  maiqr  liBiikr  eaaaa  raended  wMMmt  ngr 
greater  amount  of  prodl. 

BnouMT.— Bekqpk  iwtetkn  aeeBia  to  be  intimatdy  aModatad 
win  iBiHBBMnMMi  Ok  hh  mWM>  h  boo  Don  waieo  not  no  ip> 
flammation  haa  bam  loBoiiad  bf  desquamation  of  the  epithelium 
lining  the  nneono  wuibnBtf,  md  that^  owing  to  tbia  fiMt»  tbe 

AMiher  cause  of  the  disease  is  undoubtedly  mechanical  ob- 
■ti'uatiou  to  the  progieaa  of  the  ovum  throo|^  Um  ovidnat  This 
muehanieal  dhrtipetioB  aMjr  ba  ea— d  bgr  pt—iua  ftmn  wHh- 

out  or  within  the  tube,  by  growth,  or  as  a  consequenee  of  dis- 
tortion of  the  tnbe  prodoeed  by  adheaiaia.  It  haa  been  atated 
that  atroiAy  of  the  tnbo  is  a  eaoaa  of  extraularino  pregnanqr, 

bol  I  have  not  noticed  such  atrophy  in  any  of  my  cases.  Tbe 
tubes  have  always  appeared  to  be  healthy  and  normal  on  the 
oppoaite  side.  It  is  evident  that  they  were  not  haaltiqr  or  tiwy 
would  not  have  required  subsequent  operative  interference. 

My  experience  does  not  coincide  with  that  of  Taylor,  who 
atatea  that  he  does  not  believe  that  ectopic  gestatioL  is  produced 
by  a  result  of  previous  inflammatim  of  the  tubes.  I  have  al- 
most always  been  able  to  elieit  tiie  hiatory  of  a  previona  attaek  of 
oiflammation  from  these  patients,  and  this  inflanmwtiQB  big  fre- 
quently been  followed  by  a  period  of  sterility. 

I  have  met  with  ectopic  gestation  in  a  young  unmarried  wo- 
man, and  once  in  a  bride  of  aeveit  weaba  who  wa%  I  btfiovob  • 
virgin  when  married. 

SnfFTom.— The  symptoms  of  ectopic  geataticn  mnt  be  eon- 
sidered:  first,  before  rupture ;  seeood,  «t  the  time  ol  nftaK; 
third,  after  rapture. 

SpmptOHU  htfwif  Jh^ytsfW.— History  ot  >  prefvioiia  attaidf  of 
inflammation  and  sterility;  a  missed  period,  more  or  less  subse- 
quent, more  or  leas  continuous  diaduu^  of  blood  from  the 
ulevus;  pdv^e  diacoHifort;  bcarfak|f<towB  pidu,  paroxyamal  in 
character,  but  not  severe ;  soreness  or  enlargement  of  the  breasts. 

Physiedl  Signs.— On  examination,  with  or  without  an  anes- 
thetie,  a  small  bmsb  to  bo  made  out  in  fte  tube  on  mm  aicto  of  tiie 
uterus,  firm  in  consistence,  rounded,  regular,  and  not  pitted  like 
the  ovary,  and  at  the  same  time  the  ovary  can  be  made  out  as 
aeparate  and  diatinet  from  it 

Symptoms  at  the  Time  of  Rupture  —The  symptoms  present 
before  rupture  will  have  added  to  them  the  following:  suddtm, 


ROM:  KCTOnO  mTATION. 


imn  paSsui  eoUapM  with  ooM  ptnpinitLii;  pnoordud  oneMi' 
nm;pti»tmdmakm  Dm*;  rqiM,  tftta  pnlN  tad  dttatod  pnpUtf 
■hifting  dulncM  m  the  intraperitoneal  bkwd  shifts  with  th« 
dMBfs  of  positkm  of  the  pstitBts  Tisiblji  increased  vwakidar 
MtioB  tt  tta  tBtastliiea ;  gftst  vMttMiBcss }  sn^pnHlM  a(  whw 
or  great  diminution  in  the  quantity  of  wrimn  •  liwhn  tt  diftwta 
withont  the  aUUty  to  do  so. 

fwfmesf  JwyiM.— UB  memMHMH  imn  «•  mr  ntna  to  .  ' 
felt.  It  will  be  difflenU  to  make  out  any  small  mass  in  the  t.ube. 
ExaminatioD  under  thsM  eireoBBtaneeo  may  give  do  doe  aa  to 
dM  aalvre  ^  tiw  traMt. 

Symptoms  after  Rupture.— In  addition  to  the  symptoms  given 
before  and  at  the  time  of  mptore,  we  have  the  foUowing:  sal- 
lowid^  f aded-toitf  OBkr  of  tfaa  site  frma  absorptioa  of  Mood  pif. 
OMUt  and  loss  of  Mood;  alig^  pulBng  of  the  abdomen,  withont 
■meh  tenderness  and  witlMmt  rigidity  of  the  abdominal  mosdaa; 
reeorrenee  ot  severe  yaptwa  inm  time  to  tiow;  rilght  tOen^ 
tioa  of  temperature,  irregular  variXfaw  ni  poise  { fanitiAi^  «( 
the  bladder  may  be  present. 

Ph^.-'cal  Signs.— Vclvie  examinatkn  diadoses  a  nasa  oa  one 
side  of,  or  behind  or  in  front  of  the  uterus.  The  blood  clot  may 
be  felt  to  break  down  under  the  finger.  There  is  a  boggy  feeling 
«t  the  parts.  The  uterus  is  found  dli^Mljr  CBfaurged.  ▲  dtirMna 
Bsay  be  discharged  entire  or  in  pieces. 

I  have  not  found  the  presence  of  the  deeidua  of  value  in  diag- 
nosis. It  is  generally  extruded  too  late  and  only  after  serious 
symptonu  have  set  in.  When  it  is  extruded  the  case  very  eloadly 
sinnlates  one  of  miscarriage  and  may  be  mistaken  for  it. 

Tait  says  that  he  saw  only  one  case  of  unruptured  extra- 
uterine pregnancy,  and  Pany  saya  that  it  it  v«y  rarely  that  an 
opportnnity  n  obtaiiMd  to  oxainiiir  wi  *nred  cyst  I  have 
brought  three  or  four  such  speeime  Jiibit  here  to-day. 

When  the  symptoms  before  rupture  a.  ^re  oarefully  studied 
and  more  earofidfy  tan^t,  unruptured  eztoanterine  pregnancy 
will  be  more  frequently  met  with.  The  unruptured  easea  wit* 
which  I  have  met  have  oeeorred  in  the  praetim  of  those  who  hu.e- 
disenssed  the  subject  very  earefaUy  and  wlio  have  been  thor-^ 
oughly  familiar  with  the  very  earliest  symptoms  and  physical 
signs.  The  diagnosis  has,  therefore,  been  made  hy  them  and 
Mily  sobsequently  confirmed  me. 

These  are  no  "society  utterances  or  library  paper  ssprcsBOOS^'* 
as  Tait  dubs  them,  but  a  atatement  of  faets. 


H  WOmi  ECTOPIC  OKTATIOM. 


cele  on  the  one  hand  and  eetopie  teatatkm  mi  the  other.  We 
now  know  that  hematocele  is.  in  most  cases,  due  to  ectopic  getta* 
tion  and  that,  therefore,  the  symptomB  of  hematocele  are  prae- 
tidily  the  i^Tnptoma  <rf  eetqfne  geatation  aobntpiiBt  to  rkiptur* 
wkidnfe. 


was  iMliMBt. 

IHwebentulDiagkosb.  Bcfdw  Rt^»«.— A  diagaoA  must 
be  Bade  from  the  following  conditions:  first,  abortion;  second, 
mroma,  aarajma,  carcinoma  of  the  tube;  third,  hematosalpinx; 


fourtb,  hydroMlpinx ;  flfth,  pyoMlpinxi  uzth,  eyit,  fibn^  or 
htmatooMi  of  the  ovsrj. 

In  abortion  there  will  be  no  nun*  felt  in  the  tube.  The  aterm 
will,  in  all  probability,  be  larger  than  in  eetopie  gestation.  In 
growths  of  the  tube  there  will  be  no  qrmptoma  of  pregnanes ;  no 
period  will  have  been  miaied.  In  hematoaalpinz  and  hjrdro- 
•alpinz,  as  well  as  in  hematoma  of  the  ovary,  the  sjrmptmna  will 
closely  simulate  those  of  eetopk  giMtimi.  i  mn  the  Mses  re- 
corded it  will  be  sera  that  it  is  inpoMiUe  to  oMdn  a  diffemtial 
diagnosfa  nntil  after  the  abdomen  has  uem  o^^ncd.  In  oasss  of 
pyosalpinx  there  will  generally  be  a  history  of  inflammation 
with  an  deration  of  temperature  and  an  abantee  of  the  qrmptooN 
of  pregnancy.  A  mail  «yst  of  the  chrary  wQI  fireqrtintly  produea 
utenne  hemorrhage,  coming  on  after  a  miased  period,  but  with- 
out any  of  the  other  aymptooa  of  pregnaney.  The  <  t  can  gen- 
erauy  na  laacniy  BhMM  oih}  n  m  voo  aerae  bmi  rooiicieo  aiHi 
fluctuating  to  be  a  tubal  pngpUUMy-  The  ovMriaa  ligament  as- 
sista  us  in  emning  to  a  cmidaiitMi  as  to  whether  dH  enlargamrat 
ia  tubal  or  ovarkiB,  md,  fiulhaiiiiaw,  Iht  orary  on  that  skia  wffl 
be  found  wanting. 

In  two  of  my  eases  I  was  enabled  to  diagnose  unruptured 
ealDiria  fsttetiea  ow^  to  Uttk  vaix  laat  The  enlargMaeBt  of 
the  ovary  led  to  the  dtagnos's  of  extrauterine  pregnaney;  the 
mass  in  the  tube  was  mistaken  fur  the  normal  ovary.  Fortu- 
nately, b  eaeh  eaae  the  abdomra  waa  <qieBed,  and,  ttoi^  tiw  en- 
larged ovary  had  been  mistaken  for  the  gestation  sac  and  the 
gestation  sao  had  been  mistaken  for  the  normal  ovary,  the  pa- 
ints were  readily  relieved  from  what  could  have  been  makm 
danger. 

A  fibroid  of  the  ovary  may  be  made  out  by  feeling  the  ovarian 
ligament,  and  the  irregular  and  hard  outline  of  the  growth  itself 
is  its  chief  characteristie.  It  ia  not  Wmfy  to  be  acoompanied  hy 
uterine  hemorrhage. 

At  the  Time  of  £upt«re.— Differential  diagnosis  at  iMt  tine 
must  be  made,  first,  from  acute  poisoning ;  second,  from  rupture 
of  the  bladder ;  third,  from  rupture  of  the  stomach  or  intestines ; 
fourth,  from  intraperitoneal  bottorrhage  from  womi  otte  bboM, 
mMb  as  ruptured  uterus  in  a  case  of  normal  pregnancy,  rupture 
ot  a  pregnant  bicomuate  uterus,  or  rupture  of  a  pregnant  ill- 
developed  uterine  horn;  fifth,  a«rte  goeflndwal  endemetrMi; 
and,  sixth,  attempted  abortion. 

Ia  aeute  poiaaiiing  tiiere  may  not  be  the  symptoms  of  preg- 


'7 


10 

»«y  er  h«>ar>te|«  fto™  the  utjnM.   Rupture  of  the  bbuWer 
JVw  me  oeeomnee  and  gweraUy  a«oriated  with  trau- 
Itii^nymptonm  of  preg«iw4iia  »ot  be  pre«mt  and  there 
^l^t  h^Ln  uterine  hemorrhage.  Perforation  of  stomach  or 
"Ss^ea.  not  dn.  to  tn»nmati«n,  may  closely  B,m«late  ectop« 
gestation  at  the  toe  of  wptnre.  Symptom,  of  P;ep«J«y^ 
Serine  hemontoge  will  be  absent  and  there  wiU.  m  aU^ 
abiUty.  have  be«i  symptom,  of  pre^iating  inflammatory  or 
Ser^di-H^e.   B«.pt  i«  «—  <rf  P«<«~t7  of  a  gaMric  lU^, 
the  patient  is  not,  in  my  experience,  greatly  eoUap^d.  Intra- 
peritoneal  hemorrhage  from  some  other  «.nwe  ewmot  ^ 
Sitdy  diagnosed  from  a  ropt«red  ectopic  gestation.   Acute  .on- 
orrheal  endometritis  will  vfery  closely  shniUaf  ^^^^^ 
nterine  pregnancy.   It  is  accompanied  by  feT«r  sad 
by  a  disdiarge  of  blood  fewn  the  vagina  in  which  pus  is  found, 
aJd  a  discharge  of  either  pus  or  blood 
ping  the  same  with  the  finger.  There  »  <rfte» 
5»e  «rt«mal  genital..  Oollap«  is  not  marked ,  great  abdomind 
tenderness  is  present.   There  wiU  be  no  symptoms 
and  the  patient  will  not  have  misaed  a  monthly  period.  Vonnt- 
iBg    often  p«*ent,  as  weU  a.  rigidity  of  the  abdominal  waUs^ 
In  cases  of  attempted  abortion  there  will  be  found  some  good 
wwn  why  the  patient  does  not  wiA  to  have  a  diHd.  8y«f«» 
STregnaney  will  be  pre«nt;  temperature  very  high;  piUse  of 
inflammatory  type,  collapse  not  marked;  rigidity  of  the  abdom- 
inal  walls.   Patient  gives  evasive  answers,  though  she  may  ae- 
knowledge  having  pawed  an  instrument. 

In  the  address  on  "Midwifery"  read  at  the  twenty-ninA  an- 
nual meeting  of  the  Canadian  Medical  A»ociation,  held  at  Mont- 
real,  I  presented  the  taWi  on  page  21,  that  may  be  of  interest. 

Intraperitoneal  hemorrhage  may  occur  in  a  smaU  amountand 
,tiU  give  rise  to  severe  symptoms.  One  of  the  patients  «m  whom 
I  operated  for  extranteriBe  plUgBMCy  became  pregnant  subse- 
ouently.  After  she  had  missed  two  periods  she  was  taken  sud- 
denly with  severe  pain  in  the  side,  in  the  lower  abdomen,  and  Wt 
„  if  something  had  given  way.  She  had  a  large  hernia  from  the 
PMking  that  had  been  used  at  the  time  of  the  previous  operation 
tToheck  the  terrible  hemorrhage.  I  opened  the  abdomen,  fear- 
ing that  a  loop  of  intestine  xMgA  »«ve  become  caught  or  that 
M Had.  had  been  torn,  and  feeling  that  I  could,  at  the  same 
tiiae,  apair  the  large  hernia  and  place  her  in  a  better  oonditioB. 


tl 


Km:  tCTOnC  GESTATION. 


It  WM  only  after  she  was  ancsActued  tliat  I  wu  »l>le  to  out 
intrauterine  pregnancy.  , 

After  the  abdomen  was  opened  I  found  a  imaJl  quantity  of 
blood  and  a  large  adhesion  binding  Qteroi  to  tfwpdTie  rtrue- 
tures,  that  ha'd  been  torn  through.  fiBie  ABwed  IrtW  flo, 
in  the  fifth  month,  in  the  early  morning,  and  I  saw  her  at  3  in 
the  afternoon.  I  never  had  wash  diffienlty  in  cenoving  a  pUr 
centa ;  it  was  univeraally  adherent.   She  reeofwed. 

I  met  with  one  other  case  of  severe  vomiting  of  pregnancy 
and  ecdlapse  that  simulated  a  ease  of  ectopic  gestaticm  with  rup- 
ture. The  patfwit  was  threatfflwd  with  a  iBiM«rrii«e  and  there- 
fore had  uterine  hemorrhage  after  having  missed  a  period.  The 
pregnancy  had  been  allowed  to  go  on  until  the  ccmdition  from  ez- 
eesmveTomitingWM  extreme.  Su^tei  pain  Md  faintneas  ae*  in. 
Upon  careful  examination,  however,  a  correct  conclusion  wa» 
eome  to  and  a  miscarriage  induced,  and  even  then  we  feared  that 
tte  pcttettt  would  meeimib.  A  lew  dajn  ago  I  saw  the  patiei^ 
ag«tw  in  a  similar  condition  and  was  struck  with  the  eloae  re- 
■enUoiee  to  a  case  of  ruptured  ectopic  gestation. 

Afiw  Mvphm.—JJ^leta^  diagnorii  matt  be  made  from, 
first,  inflammatory  disease;  second,  from  tumor  of  the  ovary  > 
third,  from  pelvic  abscess ;  fourth,  from  myoma  uteri ;  fifth,  f rwB 
flnrnual  pregnant;  sixth,  frwn  pregnancy  in  tm  ffl-daydop«d 
horn ;  seventh,  from  malignant  disease. 

The  mass  discovered  in  the  inflammatory  diMase  is  usually 
ntuated  on  both  sides  of  the  uterus.  It  is  harder  and  more  sen- 
sitive to  touch.  Great  elevation  of  temperature  is  noted.  Tumor 
of  the  ovary  is  not  accompanied  by  symptoms  of  previo»  rup- 
tured eetopifi  gettation  unless  it  has  been  twisted  on  its  pedicle. 
An  ovarian  tumor,  pelvic  in  situation,  that  has  been  accompanied 
by  uterine  hemorrhage,  and  whidi  has  become  fixed  and  inflamed 
as  a  Mmaequenee  of  a  twist  of  its  pedicle,  will  be  difilcult  to  diag- 
ttofe  from  a  nma  left  in  the  pelvis  from  ruptured  ectopic  gest*- 
tion. 

Pelvic  abscess  often  results  from  ruptured  ectopic  gestation  and 
breaking-down  of  the  clot.  Perhaps  ectopic  gestation  is  one  of 
the  most  frequent  causes  of  pelvic  abscess.  If  of  inllunmattny 
origin,  the  history  will  assist  in  making  a  differential  diagnosis. 

Mymna  uteri  is  usually  more  solid  in  consistence  and  rounder 
in  outline,  and  the  voisaim  on  its  snrfaee  a  gnat  miktaam 
in  making  a  diagnoms.  "awfe  will  hw*  bam  no  snddMi  onset  <rf 
severe  symptoms. 


HOSS:  XCTOFIC  ODrTAtlOy. 


It  is  difBenlt  to  ^ttagnow  eonnoal  pregtuun^,  bat  the  wrflM 
symptoms  of  rupture  wfll,  in  all  prokitbility,  hitO  IWefc  lfliMlt 
The  same  may  be  said. of  pregnancy  in  &u  ill-developed  horn.  If 
el  Jier  of  these  have  ruptured  it  will  be  imposrible  t?  SMagtMi 
ftms  edtopie  gestation  after  fttptuw.  ftitwiWjjliwiit  jHWMilfcliiie 
will  not  have  been  any  sudden  onset  of  severe  symptoms.  The 
doeaae  is  aeeompaiiied     more  pain  and  is  of  longer  duratiim. 

I  ted  •  eariiR»  gipetfaBwe  wHh  •  eaw  tevtHg  «ik  lB-d»Mi^M 
uterine  horn.  The  patient  was  41  years  of  age,  mother  of  four 
children.  Had  pain  in  the  abdomoi  off  and  <m  for  araie  time. 
It  began  in  tin  left  iUae  region  and  passed  in  Tafioa  difeetiotti. 
In  September,  1891,  had  what  she  called  typhoid  fever  and 
peritonitis;  pain  continued  after  this  and  came  on  diiefly  at  the 
menstrual  period.  When  the  patient  was  only  21  yettt  of  age 
she  had  had  a  Inmp,  that  appeared  the  size  of  a  goose  egg,  to  the 
left  of  the  linea  alba,  in  the  lower  pelvic  region.  A  ponltice  was 
applied  to  it  and  it  finally  opened  externally  two  o:  t'  ree  inches 
below  the  umbilicus.  The  abscess  remained  as  a  chronic  ab- 
scess for  two  years  and  then  healed  up.  Owing  to  her  indefinite 
symptoms  when  I  saw  her  some  years  later,  I  ^eided  to  open 
the  abdomen,  and  on  April  9,  1892,  this  was  carried  out  at  t>><^ 
Toronto  Oeneral  Hospltd.  I  found  a  bicomuate  uterus ;  the  mass 
to  be  felt  to  the  left  was  one  horn  apparently  only  slightly  at- 
tadwd  to  the  eorvix.  Tins  was  determined  by  the  situation  of 
tliO  round  ligament  joining  its  outer  angle  and  the  abeenee  of 
broad  ligament  between  the  two  uterine  masses. 

A  year  or  two  later  I  was  called  to  see  the  patMnt  with  I!Kr« 
nown.  Ox  loromo,  ana  xonna  ner  suiieruig  ifubi  severe  par- 
oxysmal pains  and  obstinate  constipation.  She  had  been  suffer- 
ing from  these  pains  for  some  wedos.  The  rectum  was  obstracted 
tcoA  a  large  mass  irai  to  be  IMt  in  the  pelvia  md  ooOld  be  Ciit 
above  the  pubes.  I  knew  dwt  the  patient  had  a  rudimentary 
uterine  horn  and  decided  that  tiik  mass  must  be  retained  men- 
gtntA  fttM.  She  wis  not  living  wifli  hm  hnlMi^  XJpen. 
puncture  through  the  vagina  a  large  quantity  of  black,  tarry 
blood,  resembling  retained  menses  in  cases  of  imperforate  hymoi. 
esMped.  Bftd  I  Mt  knowii  the  eztet  nttare  of  the  mm  I  itwM 
have  taken  it  to  be  oae  of  pelvic  hematocele  caused  by  a  rupture 
of  an  ectopic  gestati(m  into  the  broad  ligament,  bat  would  hare 
oeen  puzztcu  oy  me  carry  appeanraee  (htm  dioocl 

€6t%ml  Pregnancy.— In  comnal  pregnancy  the  round  Kga^ 
BiBat  wffl  be  found  to  nm  to  the  outer  aide  of  the  mass,  wherea» 


ROSS:  tcranc  amaAnoK. 


in  tribal  pngnancy  tbe  roond  liguMnt  nuw  to  the  inner  aide  of 
the  BUM  toward  the  nedian  line. 

D^trential  Diagnosis  at  FvU  Time  before  Death  of  Child.— 
Thb  il^g""""  moat  be  made  at  thia  time  between  eetopic  gesta- 
tknand^s;  a  aornial  iatrantniac  pngaaa^  with  a  very  thin 
wall;  (h)  isplacement  of  the  pregnant  uterua  by  a  fibrocystic 
or  nyematouB  tumor;  (c)  bifid  uterua  with  pregnancy  in  one 
dtamber.  I  have  met  with  several  ea!"^  of  thin  utniiM  wall  with 
intrauterine  pregnancy  that  felt  as  if  le  pregnancy  must  be  out- 
aide  of  the  uterua,  but  on  more  careful  examination  I  was  able 
to  aatiafy  BQrself  that  the  condition  was  a  normal  one.  In  caaes 
of  displacement  of  the  pregnant  uterus  by  a  myomatous  tumor 
I  have  never  had  any  diflSculty  in  making  a  diagnosis. 

I  have  met  with  one  case  of  bifid  uterus  with  pregnancy  in  one 
ehamber,  and  the  report  is  as  follows:  MIm  E.,  »t  23.  Had 
menstruated  and  had  a  discharge  cx  blood  from  the  uteras. 
Ifenstruation  then  ceased  and  she  had  seen  nothing  for  two 
aonths.  There  had  been  no  abdominal  pain  and  there  was  no 
hwtory  of  collapse.  Patient  looked  in  good  healtii.  I  was  so 
uncertain  as  to  the  diagnosis  of  the  case  that  I  decided  to  use  the 
uterine  aoond.  This  passed  in  toward  the  right  a  distance  of 
atxrat  three  inehes.  A  tumor  eonld  b6  dafthMtly  made  oot,  to  tin 
left  side  of  the  uterus,  as  large  as  a  pregnancy  at  about  three  and 
one-half  months.  I  felt  satisfied  that  the  patient  was  pregnant 
and  dedded  that,  as  the  ntems  was  onpty,  the  i^wgnanqr  mait 
be  an  extrauterine  one.  There  was  milk  in  the  breasts.  Oper- 
ation was  advised  and  the  abdomen  opened  on  November  22, 1900. 
I  foond  a  tomor  that  lo<dced  red  and  exaetly  Hke  a  pregnant 
ntema.  The  sound  was  passed  again  and  it  went  in,  as  before, 
towaid  the  right  the  same  distance.  On  careful  inspection  the 
«ne  was  found  to  be  one  of  a  pregnancy  in  one  horn  of  a  utenis 
bicomis  unicoUis.  Abdomen  wr  alosed  and  the  patient  went  on 
to  full  time  and  was  attended  by  my  friend  Dr.  Mcllwraith,  of 
oor  eity,  i^  found  the  septum  present  at  the  time  of  delivery. 

JfiffmnmtilA  Diagnosis  at  Full  Time  after  Death  of  Child.— 
The  dionnntitm  in  size  of  the  abdomen,  the  false  labor,  and  the 
diow  that  occurs  are  characteristic  of  this  oonc^on.  The  cer- 
vix is  oftentimes  found  to  be  open,  and  in  my  own  case  (No.  45  in 
table)  the  finger  could  be  readily  passed  up  into  the  uterine 
eavity  and  the  bicornuate  condition  of  the  uterus  could  be  readily 
made  out.  The  diagnosis  iiiust  be  made  at  this  time  between 
(aj  slow-growing  cancer,  (b)  fibroeystie  tumor  of  the  uterus. 


aOW:  ECTOPIC  OCSTATION. 


25 


•ad  (c)  tubereular  ptritonitw.  In  dow-growing  cancer  the  in- 
ereio  is  rttady,  ud  if  tiwn  »  my  gnat  iaereaw  in  the  growth 

the  temperature  chart  will  show  evidence  of  suppuration,  tmA 
this  suppuration  will  be  moat  likely  to  accompany  an  eztrauterlM 
pttgaauey.  A  dktgaom  betwem  extrauterine  pvegnanqr  at  tids 

time  and  a  fibrocyst  of  the  uterus  must  be  a  difficult  one. 

I  know  of  a  eaae  of  tubercular  peritmiitis  with  the  nodules 
floating  about  in  the  encysted  fluid,  siiBnlrting  fetal  parts,  ids- 
taken  by  an  able  surgeon  for  a  case  of  extrauterine  pregnancy 
after  the  death  of  the  fetus.  It  was  only  after  an  exploratory 
opsratiim  had  been  performed  that  the  diagnows  was  settled. 

Treatment.  Operation.— Tail's  first  operation  wps  per- 
formed in  1883.  Operation  is  now  the  accepted  method  of  pro- 
cedure. It  is  called  for  to  eontnd  the  heaHRkafi,  to  ramove 
debris  that  may  be  dangerous  to  life,  and  to  OTweome  the  s^tie 
conditions  that  may  present  themselves. 

Some  have  stated  that  the  great  impediment  to  the  adopticHt  d 
this  treatment  is  the  uncertainty  of  diagnosis.  Tait  laid  down 
the  dictum,  however,  that  when  the  patient  is  found  in  danger 
of  death  from  coi^HioBS  within  the  abdomen  which  do  not  seem 
to  be  dearly  of  a  lualignant  nature,  but  a  correct  diagnosis  of 
whi^  is  impossible,  the  abdtnnen  should  be  opened  and  the 
diagnods  mads  eertain  and  thus  sacifftil  treatment  made  pos- 
siUe. 

He  concluJed  "that  in  the  great  majority  of  eases  of  extra- 
peritoneal hematocele,  wen  when  due  to  ectopic  gestation,  the 
disease  may  generally  be  let  al<Hie,  being  rardy  fatal,  and  that  it 
is  to  lie  interfered  with  only  when  sni^niratitm  or  extrane  temor- 
rhage  has  occurred.  That,  oii  the  contrary,  intraperitoneal  hem- 
atocele is  fatal,  with  almost  uniform  certainty,  that  so  soon  as  it 
is  sujqpeeted  the  abdomen  mtist  be  opened  and  the  hemorriiage 
arrest' 

1 1>  ke  exception  this  opinion.  I  am  satisfied  that  the 
eases  < .  ■  raporitoneal  h<.!ii«toede  ure  not  uniformly  fatal,  and 
I  have  operated  jn  cases  that  I  feel  satisfied  might  have  recovered 
H^thout  operative  interference,  and  have  left  unoperated  on 
«am^Mae%  ^  hm  reeorand,  ^  had  hsoi  ooQqised  m&  al- 
most moribund  at  a  considerable  distance  of  time  before  I  saw 
them.  The  fact  that  the  patients  had  presented  all  the  symp- 
toiBS  of  intrapnhoinal  hamotiluiy  showed  that  soefa  mm  «Mt 
mover  without  operation  and  that  they  need  not  uaemmiify  %• 
Mses  of  hemorrhage  into  the  broF.d  ligament. 


ROBS:  tCtOPK  onTATION. 


Bat  it  mum  to  sw  Uiit  waOk  fine  dktiiietimw  eumot  aerve  any 
gooa  pttrpoM.  H  >  mgaoria  mi  ht  mat  hOof  rupUu»-uiA 

that  it  can  frequently  be  made  is  now  beymid  diapnte— the  ab- 
domen ahoold  be  opoied,  nther  tiiroogh  the  abdominal  wall  in 
tioat  oe  fbmtigb  Ubi  t^ihte  %«tow,  mi  the  mmiptand  tube 
should  be  removed.  It  is  not  necessary  to  remove  the  ovary  if  it 
is  healthy.  This  will  be  a  Very  simple  prooedure  and  the  mor- 
ttBty,  in  di^liaD^a>>oaUI1watnaak«a.  men  mptnre  has 
occurred  operation  should  be  Undertaken  without  delay.  I  have 
in  one  iiwtance  taken  the  patient  in  my  carriage  at  once  to  the 
ho^tal  it  1  A.M.  in  order  to  save  cMay.  I  have  never  regretted 
rapid  action  in  these  cases,  but  in  two  oases  I  have  regretted  de- 
lay. We  should  not  attempt  to  quiet  our  fears  by  endeavoring  to 
dedde  between  tobd  ^Mp  or  mufim,  and  tubal  raptore  into  the 
peritoneal  cavity  or  the  broad  ligament.  If  your  experience  tal- 
lies with  mine  you  will  not  often  find  the  rupture  into  the  broad 

If  you  Avill  do  me  the  honor  of  earefuUy  reviewing  my  taUe, 
you  will  see  that  the  lowest  mortality  accompanies  the  eariy 
operation.  When  puzzled  over  these  cases  one  should  send  im- 
mediately for  further  advice.  We  should  not  wait  until  the  not 
day.  If  one  consultant  cannot  be  obtaiite^  viOg  to  tiw  latenen 
of  the  hour,  another  should  be  procured.  Waiting  means  in- 
OMMMd  risk  to  the  patient  and  inereaaed  diffieultiea  for  the  C|[W> 
itof.  An  operation  Is  tte  oi^  form  of  tfeaitmeiit  in  MlMii  mm. 

The  terrible  contingencies  that  sometimes  arise  when  the  con- 
dition is  allowed  to  prooeed  ue  particularly  exen4>Ufied  in  Case 
^<tf  the  table  (Mrs.  J.).  Sa'^ean,  after  opmilig^abdmMii 
I  found  the  uterus  pushed  forward ;  it  looked  like  a  uterus  con- 
ta^"»T*g  a  six-weeks  pregnancy.  Adhesions  of  the  omentum  were 
br^N»  down  and  ikmt  Med  very  freely.  An  oraeleatkm  a  flie 
mass  was  then  started.  After  a  time  the  finger  burst  into  it  and 
fluid  escaped.  Then  portion  of  old  clot  came  out  With  the 
finger  throo^  the  opening  a  fetw  eoold  be  diatiBetly  Mi  aad 
this  was  extracted.  The  placental  adhesion  was  now  reached  and 
blood  gushed  out  immediately.  It  eame  sd-fast  that,  in  a  moment 
tepenittaB,  I  ^sqied  the  right  ttterke  artery  and  flm 
clamped  the  left  one,  and  decided  that  il;  would  be  necessary  to 
perform  hysterectomy  in  order  to  get  at  the  hemorrhage.  Hem- 
onrIui§e  fMHi  tinae  aAeriMis  ^rae  Mpril^.  Tfee  putieiit  lAlMrt 
died  on  the  table  during  the  operation.  Gauze  wasJ^t^Kd  into 
the  pelvis  after  the  surface,  from  whidi  the  plaeento  iiii  IteMi  re- 


mm:  woKsto  QanAngp. 


97 


moved,  had  beoi  toodMd  wiHh  penolplMto  of  iron.  Tiw  Uood 
■eeiiMd  to  aooM  frgpv  lnndi«di 

Prmore  wu  applied  exfeBmiyay,  reetom  pid^nd  with  gaiue, 
vagina  pa«ked  with  gauM^  and  a  finn  bandage  placed  t»  litu, 
Mtttwmmamifnt^  fact  that  the  ntenia,  tobea,  and  ovariaa  had 

been  removed  with  the  map,  the  bleeding  emtinned  from  the  anr- 
faoe  of  the  enl-de-aae  of  Donglaa  and  the  aorrounding  pitrta,  ao 
tiiat  gauze  had  to  be  vmA  in  fb»  nfovonentifHied  aumner.  Tim 
patient  Uved  for  three  days. 

Sneh  an  experience  should  be  sufficient  to  warn  us  to  ntit,  in 
such  cases,  until  after  the  death  of  the  child  or  ontil  full  time. 
It  is  very  easy  to  lay  down  this  role,  bat  itia  ao  eaiQr  tor  as  to 
observe  it.  The  life  or  death  of  the  fetna  is  difltenlt  to  determine, 
end  many  operators  find  timnaelves  faoe  to  face  with  a  live  fetoa 
and  an  active  placenta,  owing  to  thia  very  diiBenl^.  1%ey 
would  like  to  draw  baek,  bnt  are  forced  to  go  <». 

When  the  pregnancy  is  advanced  vaipnal  section  should  give 
way  to  abdcnainal  seetiim.  Tait  belieiM  that  vaginal  section  is 
an  muatkfactory  method  for  the  purpose  of  saving  the  ddld. 
There  are  man>  cases  recorded  in  which  great  difficulties  were 
met  iinth  in  getting  th«  child  out,  and  only  two  eases  w^  known 
to  Mn  tst  whidl  the  eiM  had  been  extracted  aUve.  His  ex- 
perience is  similar  to  mine  and  was  sufficient  to  deter  him  from 
making  another  attempt  to  deliver  the  fetna  in  this  way.  He 
wrate  limt  fee  w«M  nemr,  nnder  any  dtvowtaMM,  atttdk  a 
subperitoneal  pregnancy  from  the  vagina.  He  considered  that 
the  child  could  not  be  dragged  out  without  tearing  tisanes  in 
i^dA  terge  sinosB  ha;v«  ben  atmovnaBy  devalued,  and  throQi^ 
Straetures  i^jrielding  as  they  are  this  can  only  be  drnc  with 
mneh  fnree  and  with  the  likelihood  of  losing  ita  life.  If  large 
vessdi  be  ttmi  it  is  simply  iuposstt^  to  fiad  flMBiand  seevt  tli« 
Ueeding  points. 

In  one  case,  that  of  Mrs.  J.  (No.  19  in  the  table),  I  operated 
in  this  way.  The  fotlo'tving  is  the  history  of  the  case:  The 
patient  had  been  ill  five  weeks.  Had  missed  a  month  and  then 
had  gone  five  weeks  after  that  and  then  went  six  weeks.  Sudden, 
severe  pain  in  the  abdomen  came  on,  and  when  I  saw  her,  after 
she  had  been  ill  for  five  weeks,  she  was  profoundly  septio.  Uterus 
was  pushed  forward  by  a  maps  as  large  as  an  adult's  head,  and  I 
was  satisfied  the  case  waa  ather  one  of  suppurating  hematocele 
from  ectopic  gestation  or  retained  BKUiteQal  fluid  in  an  unde- 
veloped ntonne  horn. 


28 


■088:  ccropio  enfri.TKnr. 


Vn.  A. 

•ho. 

I. 

Nn.W. 


IMn.  U 


HJ.  F.  W. 
BMI. 


II 


1- 


IMn.  UM 


id. 


)Mn.ll. 

76 


I  Mr*.  O. 


a.G. 
Sowe. 


BoaptUI 
wrrln 


LiUMn. 


Ko. 


tyn. 


tjn 


yn. 


C.  B.' 
Cutb- 
bert- 

•  OD. 


Only  mar- 
ried 7 
moothi. 


twain 


10  daya 

OTW. 


Wentr 
week  a. 


Sdaya., 


I  weeka. 


ScMBliar'^SirLS? 
•d  UU  Juaarrt. 
■atiilar  to  DaMa- 
btr.ilBoatlmpro- 
tmi.  Imm  I*  

wa  pah 

«<Nka  aftar.   

to  Ua  down.  DIa- 
ctaara*  oopiooa. 
UBabIa  to  act  up 
Vary  »(*k 


March  to.  IWI,  na 
w«ll;  wcBt  mm 
•eeka,  and  anala 
UBwall  JuM  t. 
Taken  with  palna 
like  labor  patau  and 
llowlnc.  Tbousht 
had  a  mlaoarriace. 
OoHaptr.  Hot 
olotha  and  went  to 
bed.  BleedlBKCon 
tinned. 

Doctor  thoucbt  the 
had  a  mUcairlaRC 
and  curetted.  Jut 

'^ 
then 


ahow. 


None....k.. 


After  mlialnir  three 
weeka    had  dla- 
ot  bkwd 


cbarga  < 
for  tin* 


I  •  ••MM  ••■•  MAM*  ••• 


Mo  rigna  of  prat- 
nanqr.  Oua  tent 
aa  oM  of  probable 
haawtocMa  or  pel- 
wio  abaoaaa.  My 
dlaaaoala  waa  el- 
tber  raptor*  of 
eetop'e  lato  broad 
Unaent  «r  - 
rtB« 
and  HI 

Nona 


ThoaRht  ahe  waa 
pregnant.  After 
the  curetting  tem- 
perature went  to 
lot*,  pulae  lit. 
TWnperatiire  roae 
auddaaly.  Tlolaat 


No  other  lymptoma 
otprenanoy.  No 
BiBUar  attack  be- 
foraoMrrlaNa.  Be- 
morad  lohoapital 
to  be  taon  cl-  iely 
walebad.  While 
tbara  audden  ae- 
Tcre  attaoka  of 
peritonttia  a»<<>' 
termlned  to  apa> 
rateatcmoa. 

Had  a  mlacarrtage 
three  yeara  before. 
Temperature  and 
pulae  normal  until 
llTe  daya  after  Brat 
atteefc,  wh<apvlae 
waatM.  ttanata. 


ROSS:  ECTOPIG  OMfATKnr. 


29 


PslMoa  UrttaR.oowth' 


After  wmliiitlon  per 
vantBua,  I  Mt  lb« 
honw.  BaMllraalM 
back.   fatlMt  ool 


DoM  oa  neoad  or  third  iter 
ter  mptiu*.  fooad  rnptiirad 
tubal  Dragaaaer.  TSoacbt 
probaMa  bmnatoaaipnz. 


aot  lit 

M 

IB' 


After  Maine  BUcht 
mtm,  taken  lllwlth 
firiB  In  right  groin 
aad  acroaa  abdomen, 
not  verj  Mvere 
Pain  In  head  and 
limb*.  Put  to  bed 
Pain  increased. 
Waat  out  week  after  I 
weal  to  doctor*! 
bouw.  Paiaraenrred 
m  three  dajra,  ee- 
vna;  la  bad;  ap- 


Marad   

Wtoin,thaan>aBd 

aowa*  rvNunoad. 
nillllli  il  labor 
jp^a.    Doetar  toM 


I  DtcathaafteraMr'  BteaO 


nta 

riage  Mii>«d  with  and- 
dea  pain,  right  fide, 
low  down  In  abdo- 
awn.  Went  to  bed, 
aeat  for  doctor.  Cold 
Bwaat.  In  bed  one 
aad  a  half  days.  Up 


Abdominal  pain,  un- 
comfortabM  but  not 
aerere,  luted  two 
weeks.  Was  striiln- 
ing  at  stool  when 
sudden  serere  pain 
seised,  low  down  in 
rlcbt  side  losrer  ab- 
•lomen,  Crawled  to 
bad.  aot  op  •  (s« 
ham  after,  patara- 


to  'Va?fe 


Larfce  mass  eztendinc 
neatly  to  the  lerel 
of  umMllcns,  dull 
on  percussion  and 
fluctuating.  Utems 
three  and  a  hall 
Inches  In  length, 
empty  and  In  centm 
of  perns,  pressed  by 
the  mass  back 
aaalnst  sacrum. 
Diagnosed  suppurat- 
ing hematocele,  but 
801  sore  whether 
dna  to  ectopic  gesta 


^   felt  OB 

ri|^  aide  of  abdo- 
men, low  dowa,  IB 
froBt  of  ntaros  aad 
appareaUy  betwi 
utema  aad  bkMlder, 
not  morabla  or  flae- 
toatiag.  Otagaaste 


PeWla  AIM  with  a 
mass.  DIainiosrd 
ruptured  ectopic 
Restetion,  com- 
Bumeing  snppura- 
ttaohnateblMddot. 


Operated  abotM 
week.  Ar  ' 


•tettartaath 


Tumor  Mtbi  right  la-  Doaa about  thirteenth  or  four^ 
H!5i"'»i}«lV«»F  traathwsek.  Masa  fouud  ap- 
**^:.  yirtteHay  pareatly  la  broad  Uguaeal 
Osrvtz  aad  aot  reaiofabla.  Boiopti 
gtatatloa.  Opeaed  and  wash 
~7  T-z-  adoataaeaaddrataed.  Bern 
i5S=z  =j=i»Jj2-  on*agaatlBter»alaforao»r 
pSSKiS^TJm?^  U.-k-arthsfrom 

Jnaa  n  walked 
hoivttal.  Izaai 
tioa  found  Bteas.  TO 
ratWB  In  two  da^ 
Uader  chloroforra  a 
inorable  masa  (ait 

drOBB|M[  iBlO 


Doae  aftt  flre  weeks  of  sup- 
purattoa  Patleat  profonadly 
septle.  Washsd  oqt  chrts 
from  abdomea  aad  ramored 
fetel  sao  of  about  twelfth 
week  (rem  amoaa  tataattaea 
-and  uneoBBcoted  with  tube, 
niote  iB  abdomen  had  become 
aatonr  ad- 
!a  aad  had 


ersd, 


Be- 

COT- 


COT. 

ercd. 


Operated  i 
Toroato 
Hospital 


Died. 


encysted  by 
baakMaof  - 


Fouad  secoBdary  rupture  of  a 
aupporatlBg  seBrf-orgaalsed 
old  ceto»te  gtiteUsu  dot 


Re- 

COT- 

ered. 


Eighth  to  tenth  week.  Abdo- 
men llllpd  with  blood,  gru- 


Sa- 

OOT- 

arcd 


3 


Mn.II. 


MBoWM 


a  Mn.  P. 


3jf 


•  Mn.H. 


3# 

lOMim.  B 


Doetor. 


T.8. 

wan. 


n 


I  a. 


Ubon. 


Me. 


1  yim. 


H  BMpttal 


lar. 


J.T. 
Fother- 
inftSuun 


t  wmkt 


tokiM 
blood 


OUmt 


Mr* 


Ir  •IVWM&  Mkni 
with  fMntnm*. 
Dootor  found  her 
IB  MBil^laptrd 
coadiikw;  colii 
pKrapiraUoB  and 

ward  oonplalDol 
of  Irritaunir  of 
rectom;  4uMu- 
■too.  Improved 
aodwHup  Taken 
111,  aad  dootor 
thiragbt  hjraWri' 
oal.  A«alB  Im- 
prorcd,  and  then 
Motbrr  attack 
wiMB  I MW  bar. 
,|Tamiaroa  pregwe. 

aiSTtMittoltMS!! 
bookadllL 


Ro  vmptOBa  of 
pmoaae).  Out 
walklBKWiwn  nd- 
denly  ntaed  with 
pain  in  abdomen. 
fWt    faint  and 


ttUTM 

IttOT^B  

fana(MM«ela(,Moi 
lijr  Iwdftili  iMiwtu 


At  OBO*  oooetaiM  H 
wH  raptnrpd  utim-i 

•lOtlBMlvta. 

oidcd  to  wait  ooviito 
of  (■»■  to  pnimf 
■mt.  but  luddenlT 
took  wom,  aiid  <to- 
ckM  to  opento  im- 
mcdiaMr.  Con- 


0odar  MM«tbatlc  felt 
blood  clot  brpsk 
down  under  my  fln- 
gerini«(ina.  Outer 
•Dd    ct    tube  felt 


OMMd  ud  Mwr- 

 — ntVoT  tiloodlBcta- 

•lc«M0( OoailM.  PmMoM 
cctdBifl  ttniRMme  otaktmt 
third  Soptuw 
tbromk  tolitiM  miSat 
tube.  Tab*  end  damped  with 
forcepa  to  itop  baaorrhace 
retue  not  fooad.  PIseeoUl 
tlmie.  Enlanted  tube,  slae  of 
■mall  oraan.  data  waahed 
out  aad  drafaafa  tab*  luert- 
ad.  TttbetMwttheOk. 


Oold  haade,  denrewd 
polee,  pale  Opi,  aU 
appaaraaoe  of latrs- 
abdominal  hemor- 
rhage. Found  blood 
clot  la  abdomaa  on 


Operated  Ineide  of  an  hour  after  BC' 
lint  leelnic  her.  On  opanloK  cot- 
abdomen  blood  cnahed  out.  ered, 
Enormooi  quaatltir  uncMted 
blood  free  In  peritoneal  car- 
\*Z-  Left  tuba  aad  OW7  tied 
"Hghthagjmaniiiuua- 


iTr 


fcnai  tubal  a  ealatlua  ruptured 
Into  btvad  Umunent  on  left 
Me,  and  remomd.  Alao  eju 
of  onrj  and  dilated  tube  on 
rUAt  aftla;  pealed  oit  ~ 
aajuuiyi  aad  Ugt** 

O^TMBpia  Qb  my  ' 


full  of  Mood, 
■ctopic  aeetatloB  In  rlRfat  Ma. 
Placenta  eztrudinc  tbrounA 
rupture  In  tuba.  Tied  off  ped- 
icle. Petue  about  one  bch 
lone  Axeoonaa  peritoneum 
cut  ttaioutrh,  blood  ipurted 
out.  Inormoua  clot!  and  iuld 
blood  lemoTod^  Waahed  out 


Died 


Operation 
Toronto 
General 
Eoapttal 
NoTembar 
It,  IMS. 


rant  pia- 


truded. 
IMui  aa 
eapad  into 
Mdomaa. 
peeSSr 

QStS 


niln.w. 

UiMni  r. 
Mn.  L. 

HMn.  8. 


I  Mn.  T 


0^ 


r.r.  Me- 


J.  w. 

BOW>D. 


IT 


Mn.  B. 


6^0 


)Mn.W 


M.  WrI- 


W.J. 
rietob- 


He. 


IT 


» 


lar. 


T.  Web- 
■tar. 


two 


mat 


H  bMMi  to  taim; 
aovlferaeMwA  • 


Uttto  wkttf  la  Jas- 
aaa.bMkMboM 


■Ufciiii  tofM  to 

-  


M—iUU' 

Ttoi  oa 


aad  Umb 
waat  5 


P>Aa  . 


I 


I  montbst 
:  and  then 
I  beKan  to 
,  flow. 
Se»er 


recolar 
Am*  flnt 
babr- 


•4ari. 


Menitniated  in  Jan- 
naiT  and  rM>ni- 
ary.  MlMOd 
March  and  April. 
In  May  raipilar. 
but  (mall  quantitjr 
and  Terr  painfnl, 
and  faint  spells 
walUag  or 


Ob  Majr  ti  obwoB 
and  eottouad  aa- 
tU  Juaa  IT.  WeU 
(oratawdaraaad 
ttaDoama  on^o- 
Opmtad 


sss^ 


Heart  beat  hM«ttr 
with  leMt  excnlM 
orezoitemaM. 
SwellioK  of  limba 
and  pains  from 
knaas  downward. 
Appaltta  poor. 
Vtotoont  daaira  to 
urtnata.  aad  pain 


nttttcmt 


fait  iSoSm 
tattal  somathinn. 
aapaciallir  wban 

ridlnrbl  

Faimtal 
Some 
oiot 
Ro 


On  namiBMloi  feoad 
ricbi  tub*  mnall  at 


■to( 


)lMtMlalB 

J,  MM  teiat- 
«4.  Ootte  wall  pra- 
TiOMfr.  Tkte  oe 
coirMatlr.*. 


l'»ln  cune  oo  (addMi- 
I7  and  iHMd  two 
houn.  VsiTMTm 
PWd  aonManaek 
■eblng  aeroH  bow- 
ela.  OouM  not  baar 
clotheato  touob  bar 
after  pain  eeaaad. 
Pain  oommenoed 
witb  flow  and  In- 
craaaad  each  day. 
raintad.  Ratchlog 
dnrinf  time  of  pain. 
Oonttanad  for  two 
weaka  before  opera- 

ttOB. 

Intenaa   pain  about 
toar  wena  prertona 

to  operation.  Three 
week*  preTiooa,  ae- 
Tere  palm,  and  oon- 
tinned  for  theee 
thr«e  weeks.  Pain 
Uka  diaeoBif ort  from 


•sMrlatadSTS 


— lotfT  Hoa 

man  fall  of  1,  ,  _ 

MMood.  Tabaaoti 
bat  bioad  oooM  ba 
I  out  by 
1  tad; 


pncnaaer 
hadautoi 


brialad 
dialaad. 

P"gw»  •«  »i«  »^S««>?^  «»»ltJ  h«U  o*  blood. 
>  •.     ii...t.  waahad  out  eaonaaaa  elou 

from  bahiad  alam.  fiba 
eoatalalnit  tea  or  t  mSi* 


^  Baada  cold 
raUJd,  uxlout  ap- 
pearuee  of  face. 
Polaeieta  at  wriat. 
Prtoordial  unaaai- 
naaa  lying  on  aide. 
On  tamloir  on  baek 
dnfawea  introat  die- 
apoeared,  ihowlaR 
oTIdenaa  of  flold  ia 
Wrttoaaal  cavi^. 
•Mac  of  tolaaaa  b 


round  large  maa*  tying  in  left 
broad  Uinmaot.  ned^oJt  left 
tube  aikt  orarj,  aad  remored 
old  eotoDks  caatation.  Sz- 
trmnely  lumcult  enuoleatloa. 
Rigbt  lube  and  ovary  louia- 
what  Bzed  and  durlas  exami- 
nation b<>gan  to  Uaed,  tbere- 

_  fore  removad  tbem  alio. 

BM»o»od^taaBd(OTaiy  „ 

towMSMafSdRuum.*^"" 


I 


«f  Doug' 
dot. 


*Mwd  MM  ia  troat 
wTalanN  «■  right 


Under  aaeatbetic 
found  maaa  to  toft 
side,  and  ooaetaded 
ntrauterlaa 
naney. 


Drew  up  ectopto 
tared  to  a  aH 
under  autfaee. 
but  DO  blood  ia 


Re- 
er«d. 


Re- 


UMn.  J 


n 


Mra.  p. 

40 


Hn. 
MoT. 

Mn.  C 

^^ 

run.  L 


▼mo> 


J. 
Dwyar. 


».  W. 


•  T.llc- 


a  Me- 
KeaM 


Ubon. 


No. 


Mot 


1  BOMh 

Tkanwant 
6we«ki. 


ter. 


J.  F.  W. 
Boa. 


A.  tadto. 


MlMd. 


««Bt6 


Ohm  01 


1  ■onth 
before 
mats 
waeki 

overtime. 

Hived  1 
BiMrtblr 


on  ud  iMtod 


ewne  oa 
■ad  ooa- 
tianed  8 
week*. 


MiSKdt 
period. 


•ttaek  of 


batMMlfinvMa- 
tkm.  T«tjr««ak. 


jlaaelith- 
t^Mt  ovary 

 ata.  In 

eraeied  peristaltir 
■etton  at  boweln 
noticed  throuKh 
■Un.  XndeaToreil 
to  gat  up,  but 
falBted  three 

Vomited, 
of  abdo- 
I  Bot  in- 
ereaned.  Tempera 
tnreeleTatcdto99° 


«  of 
Pnlwi 


When  doctor  mw 


Seeoad  operation  for 
cctoptegeettiioD. 


While  in 


atora  mddra 
wltti  palD 
■Bd 


Mptia  Vtmxm 
ymktt  forward  b* 
■Mi  tbm  ot  mtaiA 
hmd.  OMMd  cBl- 
d»«M.  ftaaU  nil- 
(ol  o(  «loli  la  tin* 
at  ' 


Hum  found  behind  ate' 
roe,  niliu  aBl-de«ac 
of  Douglia,  nad  ez- 
taading  from  (ight 
tolittiid*. 


1401 

Omf  .   

Had  toopea  aMtaawto 

InestnwlioaetfMji. 

After  dUBenit  mwitpeUittoe  of  Ke- 
ilngan  la  eaMe-aa*  ct  Done-  ooi 
tae.     tateatlBiil    •dbe«ionel  ercd 
bnAcB  down  and  Mood  elot 


Urethra  on  „ 
tion  rliowed 
or 


wowed  ^Bjpne 


BMMia.  nohad  aarHv  of 
mem  tJSi. 


i 


■helled 


■eteale  ■Htattoa  at 
■d«aSial\SbaoaMt 


■  •■■Mh«(«M,air 


Re- 

OOT- 


Two  or  three  dajre  af- 
ter abdooMn  ewoUca, 
dnlneea  on  pereoe- 
■ion  on  lide  been  ly- 
iaton.  rurtatfaam 
could  feel  blood  ekx 
breakdown. 
fOnad. 


Drained, 
■eloplo  geitation  at  outer  end 
of  tube  on  left  aide,  eighth  or 
ttath  itaek;  iwaoved.  Tnbe 
renoTod  by  chain  oatgnt  m- 
tare,  hot  thleellpped,  then  tied 
withellk.  Peritoneum  darken- 
ed. Inteetlnee  corared  with 
blood;  pelTiB  full  of  blood. 
Oranr  not  remofad.  atthmich 
■mair  flbroid  aajKtla  on 
rarfaee.  Clota  " 
No  drainage. 


geetatlea  Mad 


out  eetovio  

naidtr.  Seooped  out  hand- 
fob  a  Hood  idat.  btaaHan 
dark-oolgtad.  Waabcd  oat 
Orataad. 
IMoBla  ■iilallL  n  on  right  ride 
Tnbe  and  oraiy  canorad. 

tab  paStM  af  Maad  etol 
eeooped  «at  of  perttoneai  cav- 
~T.  Waabadontaaddralaad 
eetoptc^iMatloBaae  eaal^ 


mt  aai  «Maaed 


.jRemored  eetopio  gtetatiaB  of 

I  right  tube,  *  — 

{  ovary  behind. 
:  ovary  adherent 
and  remored. 

.  iEctopicnitatlonof  aboutelgMh 
week  fn  left  tube.  Tube  and 
I  oTarv  remoTTd.  Aleo  oyet  of 
■  OTery. 


third 

ter. 
Re- 


Re- 
cov- 
ered. 


Re- 
cov- 
ered. 


Re- 
cov- 
ered 


QMraliaa 

Toronto 
Ocnml 

im. 

OpnratloB 
laa  B09I- 

Miitataak- 

Unmi 


'nmn- 
lured. 


36 


BOH:  acTono  obbtation. 


jBlIn.J 


TV 


Mmm. 


Mn.  L. 


U5 
aoMn.  C. 


as  Hospital 

lenlce. 


as. 


U 


lIn.W, 


US'- 

Mrt.S. 
Hn. 


Hn.  K. 

■n.  S. 


Dootor. 


O. 
Parker. 


G.  Gor- 
don. 


A.Eadie 


W.F. 
Bryans. 


Mo. 


Menae*. 


Kot 


Mom. 


1  week  over 
period. 


Not 
miM- 
ed. 


Kot 

,  DliM- 

ed. 


SooM  attor  bIhIbc  Three  MatiBC  at 


HemorrluRe  about 
two  weeka  pre- 
vioualy.  Dootor 
thoufcbt  a  mlMsar- 
aad  caret 


A  tew  daja 
past  peri- 
od. 


1  period. 


Imgolar 


OtkariVMVtoaia. 


Itautmated  ooo' 


aadailkte 


at 

Itboaciil 


NipiOes  looked  du'k. 
Falntneia.  Al- 
most died  from 
tbia.  Went  from 
one  talBt  to  an 
other.  BeTatioD 
of  temperature  to 
israttarearrstte- 


In 


btanfcd  brtaats. 
■Ok    la  theai. 


Doctor  found  her  al 


SUfhthaaNRhaKe. 


with 


cUed 


amais  ooi- 
aMl  fWat- 
Doator  de- 
had 

but 


tkm  oatfl  my  re 


In  two 
tluee  dajra.  af- 
ter rallying,  taken 

home. 

Fainted  three  or  four 
times.  Beads  of 
penpiratloD  on 
fawiaail  PBlae 


87 


Cnunp-llke  pains,  pu- 
osjinml. 


luaa  Middenl*  with 
MlB  while  iB  ohureh. 
Ckrried  to  •  kooia 


Tak»  in  at  noon  pre- 
▼ioin  day  witli  «ad- 
daii;wm«  pain  in 


OIMM  paekod  high 
op,  tuunwlit  < 
larged.  Pawd 
muHl  two  and  a  half 
tneliM.  ITtenu 
piwaed  forward  and 
latinetlT  felt  on  out- 


UOM,  OckMtru. '   oa  ri«lst 


I  Wf»  toaTteg  towa 


on   table.    Saline  baneatb 
breaiti.  Draiaaice. 
Aa  Extrauterine  pra«DaBer  about 

•bdoalBal  oMr,  M  eiota 


Two  weeks  after  when 
I  WW  her,  found 
maia  nUIng  pelTie, 
■eal-OBCtaaat.  Tern- 

to 


Utene  puriied  CsrwaML  looked 
like  contataied  liz  waeta  fetus. 
Broke  down  adheetoaa  of 

omentum,  bled  f reelr.  When 
mass  bunt  Into,  fluid  and  por- 
tions of  old  clot  escaped.  Fe- 
tus felt  wltb  flnger  and  with 
placenta  remoTed.  Blood 
gnabed  out  immediately 
piaeeate  touched.  Uterine 
arteries  clamped  preparatory 
to  hyiterectomy.  Portion  of 
left  ovary  left  behind.  Hem- 
orrhaite  from  adhesion  ter 
ribly  profuse.  AUnost  died 
on  Ubie.  Necessary  to  pack 
with  iraaae  after  toucnlng 
surface  with  iron,  rressuie 
externally.  Rectum  paded 
and  Taglna  partially  packed, 
■otopk!  na£stion  and  hirge 
mass  ouuide  of  tuba.  Hole  in 
side  of  tube  quite  Ism.  Be- 
mofedmaa.  Bowel  folded  In 
over  site  of  oU  clot. 
8ao  flmly  adbstent  to  omen 
torn  and  abdominal  wall.  On 
f  rii^tful  hemor^ase. 
■  ■  latoeacD 
removed 


Hemuiihaae  continued 
jyrtBrigtoiiiiBal  wall. 

toba  raoMvad.  Ataoat  died 


Died 


Re- 
cov- 
ered, 


Re- 
cov- 
ered, 


Re- 
cov- 
ered. 


Removed    ectopic  geatatioa 
from  right  broad  tta  iieBt 
siae  of  cocoaaut.  B^Eior- 
rhage  coasldenhia.  Keoaa- 
aarv  to  pack  fai  gause  to  con- 
trol.   Snbcntaneoos  Injec- 
tions under  each  breast. 
Omentum  adherent  in  fi-».t. 
Pulled  op  and  out  fras.i'<l 
quart  or  mora  of  Mood.  Re- 
moved Mt  tuba  aad  ovary. 
Oesutkn  near  vMlM  aad  aft 
tube.  Qaoaa  pMiatf  to  eia 
trolooslaK. 
Abdominal  cavity  full  of  blo>  d 
fluid  and  dots.  Point  of  het  i 
orrfaage  difficult  to  find.  Ri-- 
movsd  tubO'Ovarian  cyst  on 
one  sMe.  Blood  ooaiog  droi> 
by  drop  from  small  spot  when 
tube  eaters  uterine  wall.  Con-; 
gested  appearaaee  of  vestelil 
indfciated  voy  early  ectoplci 
>estalk»,  Interstitial  and  of  a 
few  days'  duration.  Salines 
injected,  arms  and  leas  ban- 
daged,  foot  of  *«ble  elevated 
everything  to  sustain  life; 
almost  coDayied  aa  tabla. 


Ra- 


Re- 
cov- 
ered. 


Died 
same 
af- 
ter' 
noon 


ation 


St-Hi- 
ehasll 


98 


Mmm. 


Mn.  L 


n 


lIn.P.n 


5 


n.a 

■wtttt. 


R>  C 

uninth. 


aRMn-R 


Mn. 

J.L. 


41 


A.  EmUc 


[t*.  B. 
Mn.  L. 
Mn.  E. 


Mn.  T. 


Daator. 


Lirimn 


No. 


W.  J. 
Fletch- 
er. 


DO  A.  Eadle, 


W,B. 
Waltera. 


T.  Noble 


A.  Eadle. 


O.H. 
Oanetb. 


MHn.  R 


■OD. 


Only  m 
lied  7 


ITOI. 


4  year  aco 
ninad  4 


Not 
mlw- 
ed. 


Not 
tnlw- 
cd. 


Begu- 
lar. 


Notaanw^aaaaaal 

InNovaflBber. 

oo.i 


«.••«•*••«• 


OtiMri 


CtaraMoo  of,  trai- 
peratare  after  aec- 
ond  attack.  102°. 
Pale  Upa,  quite  pal- 
lid whan  1  law  nar 
atBlgM. 

Poor  health  for  aome 
tlaa.  aaaaayaan 

tiOB  JoitlaK  IB 
r-  -  to  honMal 
brouffht  on  tamam- 
maUon.  Bore  aod 
dMndad.  Etora- 
tloB  of  tampeia- 

BentowWtilde.. 


  on  and 

laated  Umr  dayi 
looKtr  tbanaaoaL 


No  aymptoiDa  of 
praRnaocy.  Bath- 
ed la  ooM  pargta- 


Tboo^t  Bhe  r  waa 
pregnant.  Coo- 
ilderablylB  dia- 
tended. 

Hoi  aymptoma;  of 


In  Auguat  awnatru 
ated;  In  Septem 
berbutTety,  very 
little;  October 
very  aHghUy. 
Soine  ptecca  of 
deoMva  bttd  eosie 
•way. 


Takes  B  ^ 
Tfamrwttk 


open 
bed 


1  period  ..  Some...  . 


i  montha 
aso  mil* 
M 10  day*. 


Beiian  to  Uaad  and 
contiattad  four 
weeks.  Seelor 
aaya  be  saw  pla 
c-nta  and  that  abe 
hadanriaewrrtaira. 


No  bnaat  aiatp- 
tonu.  Very  weak 
and  ptoalrated. 
Manand  to  dnw 
hanaR  sjprtain 
•Bd  Ue  down. 

Thraa  mootha  ago 
bad  atekneaa  at 
atooaob,  paln. 
Prarioaaly  oparat- 
adoBlnrdvaywn 
hafwaCar  omHm 


TkiM  ■Maoka  of  m- 


iBdateitapaiM... 


One  tUcbt  atUok  of 
MiD  wban  eraeuat- 
in(  bowels.  Three 
week!  after,  aerere 
attack  of  paiD  while 
lying  In  bed. 

Serar*  pata  la  abdo- 


8udd«i,  tennv*'-'  In 
abdomn  what  walk- 
lnKoaafaaat.^1^ 


iioca. 


A  mk  before  had 


behind  utama, 
and  latiiaed  blood 
dot  poured  uot  br 
mptwwd  ectopic 


fwmd 
first 

AdTiiad  watUaf 
weeks.  Than  found 
enlargad 
■Ue. 


to 


Large  blood  okXbaUad  a  ^— 
Gaatatloa  lao  in  tntaaaettlag 
np  to  left  oa  top  o(  dot,  about 
twelfth  V  '<ek.  Hemonhage 
la  tube  boyond  produoing 
heraatoialplnz.  This  leaked 
Into  paritooeal  miHtf  ia 
■mall  quaatitiea,  owing  to  ad- 
hedoaa.  BaoMiTed  t^  and 
ooatenta.  Draiaad. 
■mall  nodule  iBamoTed  hematoma  of  right 
oTaiT,  alao  ectopie  gaatatloa 
of  right  tube  daa  (3  end  of 
little  linger,  unruptured. 


to 


VMiUar  eolottng  of 
aUn  and  collapaud 
hwk.    PaH  bSod 

---^ 
to  Mt 


vsd  gartatlon  aac,  four  to 
atx  wceka'  duration,  cnbo- 
abihiaahial.  Large  aaooat  of 
aHiaiaHovaa4 


Fonad  adhataal  

olarai,  laiga  aaioaat  of  old 
awparallag  doc  Kaptufsd 
aetata  gaataMaa  about  a  yeai 
ago  aad  aoppaiatad.  Vary 

th 


Re- 

COT- 

eied. 


asd  of  right 


BamoTcd  ectopie  geatation  of 
b»rt  inbe.  tttbo«bdomlnal. 
Alao  large  nnaa  of  Uood  dot 
Waabed  out  with  aaltaolution. 
Drainage  tuba. 
Small  ectopic  «estatk>n,  fror^ 
tea  dara'  to  two  waaha'dBca. 
tloo,  in  left  tube, 
with  ovary.  Abdoma* 
blood,  waahedout. 
Abdominal  caTlfrr  full  of  Uood. 
Ectopic  geatation  aac  under 
folda  of  omaotnm  and  run- 
alov  up  to  aumnnded  ntllo- 
ptantube.  Removed  thia  and 
« jile  doing  ao  tore  olT  tube. 
BMBoead  tube  and  orair. 
niaa  Mood  poured  out.  alao 
■aatattaaae  bMt  aide  about 
nwaaaadahalfmontha  Por- 
UmtoiMtoaarrlaft  Waahad 
oat  Md  draiaad.  aaltee  In- 
JaMad 


~  thhkaaaa  of  Oagar, 
^-iaalr.  Miofbtood. 
- — vie  gaatatioa  of  foor  or 
tre  wiift  IB  rigkt  tuba,  ta- 


moved  with  tube 
behMTMMkI  miiiiilu 
■*      '*  rupture  Into 


ered 


wRhBa- 


Re- 


Rc- 

OOT- 


Ra- 

COT- 

aiad. 


Unim- 
tured. 


Ra- 

eoT- 


Re- 
cov- 


Re- 


Ra- 

OOT- 


llamatliyi 


OomUAI.  FBHOIAirOT 


nn.B.» 


Doctor. 


Dr.  Mo- 


No. 


•  5rrf, 


Monna, 


Not 


Om  mlioatrlaitr. 
MeoitruMed  J  air 
1.  ISM,  beosnui  ttl. 
Mb  Soptcmber  M, 
IM.  La«t  goao- 
tlt7  of  btoodoM 

WMk<  TbMC#MMl 


ted  of  Btptviubor*  a 
■wollluf,  riM  of 

iMTRComn,  to  be 
frit  Ic  right  iliac 
TofcloD.  Doctor  In 
ooMtant  attond- 
•occ  (or  bearlDE- 
dowD  paiu.  In 
bed  two  moBtba. 
Larga  witli  ohUd 
whan  aba  got  up. 
LegaawcUad.  Felt 


Ijagai 

lite  In  left  aide. 
Bicaata  luve  and 
bot.  Felt  life  be- 
fora  Obrlatmaa 


Op«ied  the  porterior  enl-de  me  tiiroag^  tiie  vftgiiui  and  re- 
moved a  small  pailful  of  dots.  These  clots  were  in  different 
stages  of  dflcompoHition.  It  wm  found  to  be  impowibhi  to  cte- 
Ihrer  Am  fetas,  aad,  as  a  oanacywea,  I  was  faread  to  opea  tito 
abdomen.  After  the  abdomen  was  opened  I  was  able  to  remove 
the  fetus,  about  five  and  <»e-half  months,  and  hastily  ekiee  the 
«^)eaiBt  aad  padt  fta  aai^  af  liw  hematoede  with  gaaaa.  The 
polaa  had  now  reached  140.  Tba  patient  did  not  stand  operation 
well.  Oave  a  very  unfavoraUa  progWHis  and  left  for  home. 
She  died  within  a  week.  There  was  not  much  hope  of  reoovaiy 
in  this  case,  owing  to  the  profoundly  septic  condition  of  the  pa- 
tient, and  she  died  from  this  prolonged  sepsis  and  not  as  the  re- 
sult of  operati<Hi. 

I  mention  this  case  to  show  that  even  after  <^ration  has  bt  n 
done  throuf^  the  vagina  it  may  be  impossible  to  deliver  the  fetus 
safely  in  this  way. 

At  FvU  Ttme.— Tait  thought  it  advisable  not  to  operate  before 
the  child  is  likely  to  be  viable,  provided  the  delay  necessary  does 
not  jeopardise  tiie  mother;  and,  further,  that  after  the  death  of 
the  fetus  <^>«ntk»  should  ba  done  without  ddajr.  I  think  that 
this  is  v«7  sound  advise. 

Any  attempt  to  destroy  the  fetus  by  medicines  or  the  elartria 
current  is  to  be  candeainad.  Ifany  instaneea  in  whieh  tUa  haa 
been  attempted  have  resulted  fatally.  After  the  death  of  tito 
child  growth  of  the  placenta  may  c(mtinne.  I  had  one  such  case 
in  which  the  woman  bled  throiq^  the  drainaga  toba  for  a  period 
<tf  two  months  after  q^mtka.  Tb»  fitaa  ana  zamoved,  but  it 


1 

AprttlS,  lair.  mow 

MftMOMM  OB.  SSBt 

tor  dootor.  Paint 
emmi  aad  did  not 
rMan^t  taMMd  > 

PrtTtoorty  brM  III 
off  aad  oa  tor  two  or 
t^roo  wMks.  Dootor 
n^Mtod  drilTtry  of 

DIoohaixe   of  blood 
from  vairtM  nsdw 
enmlnatiaii.  wtth 
clots  aad  d«bri(Uk« 
plawnta  ordaddoa. 
Ooaalaa*  pala.  Es- 
taraal  iialjMlaa 
nm  fotal  nrtllb 
round  ateraaliMtk 
all  ualoolUa* 

rmporltnaaal  fat  yww  abuB' 
daat.     Opaaed  parltooauai 
aad   atomod   all  Ueodtat 
points,    nrai  adhaslons  to- 
ward pub«s  In  froat,  blad 
freoly.  On  prssatag  abe*e, 
Ihild  gnahad  out    Bao  waU 
iMlBiad.    Uqaor  aauitt  la 
■MliilaalcaTlty.  Petua  fall 
Mar*  icmoTsd.  Faalaasd  taa 
to  abdominal  wall.  Cord 
dmwa  out.  Dratead  oavl^. 
Flaoaata  Tnitiiiiiilia<l 

Ba- 

OOT- 

ai«d. 

wu  not  eoniidavd  adviiiU*  to  riaiove  the  piManta.  Whrthw 
tius  bleeding  occurs  as  a  conaequence  of  growth  of  the  placenta, 
or  of  a  single  detachmoit  of  portions  of  the  plaeenta^  it  is  diil|> 
nfttoMgr.  A piaee of idaoe^ nIdM wi tttwo ^eodsaei fra^ 

quently  grave  hemorrhage  for  two  or  three  months  after  mis- 
carriage, and  yet  the  placenta  does  not  increase  in  sise  or  grow, 
aad  when  removed  it  looks  organized,  but  not  pitei^  aadi  doaa 
not  give  rise  to  the  idea  that  it  is  active.  I  presume  the  same 
iModitiaii  may  exist  within  the  abdomen  after  what  correspond 
to  a  partial  miscarriage  is  eiEaeied  Jhgr  means  of  operative  intav 
forenoe  and  the  fetos  has  been  removed.  One  thing  is  certain, 
that  surgical  interference  in  the  fourth  and  succeeding  months 
when  the  fetus  is  alive,  is  extremely  dangerous,  and  surgical  ift- 
terfuaaee  in  the  fourth,  fifth,  sixth,  and  seventh  months  is  man 
dangBfoas  ttaa  it  ia  towaxd  the  end  of  gestation;  aad  that  toiv 
gical  interference  at  any  time  before  the  death  of  the  child  ii 
muidt  more  dangwons  than  it  is  after  the  death  of  the  ehild. 

Fidt  2^  a/tsr  D«ath  of  CkOd.— There  is  danger  to  say  wo- 
man who  carries  an  encysted  fetus.  Abscess  may  form  at  any 
tine  and  the  fetal  parts  may  be  extruded  tiirough  the  vagina, 
titroiq^  Ite  reetom,  or  thnmi^  the  Uadto.  But  soeb  a  «^ 
dition  need  not  be  incompatible  with  «  klig  wmiA  H£a^  pt^ 
vided  that  no  abaoeaa  forma. 

I  aaw  a  Ufltopediai  removed  by  Prof.  BUlrt^,  when  I  was  • 
s  Indent  in  Vienna,  that  had  been  carried  in  the  abdominal  cavity 
forannmbnrof  yeara.  The  patient  died  aa  a  resalt  of  the  oper- 
ation. fitetedBOtbecBgn^maaBT«^aBaedhyhtt«aHittkgi 


■ad  I  him  alwagm  felt  that  it  would  have  been  better  to  have  let 

Treatment  of  Placenta.— In  the  caae  on  which  I  operated  the 
plaeenta  was  left  in  litu.  The  opening  into  the  wall  of  the  aae 
wm  ftMlmed  to  the  abdomiinal  opening  and  a  Fergnaon'a  apeeu- 
Inm  waa  paaaed  in  to  act  as  a  drainage  tube.  SjrmptooM  of  aapiia 
developed  and  irrigation  of  the  sac  waa  carried  out  at  frequaat 
intervals.  The  plaeenta  came  away  pieeemeaL  The  sae  ftMiBj 
doaed  and  the  patient  made  »  food  XMOfveiT*  tbon^  tt« 
valescence  was  tedious. 

Tait  considered  that  the  umbilical  cord  should  be  divided  doae 
to  its  placental  origin,  that  the  plaeenta  should  be  emptied,  as 
far  as  possible,  of  blood,  and  that  after  waibfaiff  and  oleantng  fte 
-  aac  it  should  be  hermetically  sealed  by  closing  tha  opening  into  it 
with  atitdiea;  and,  further,  that  if  aymptoma  of  aeptieemia  ariae 
the  aae  ahoold  be  reopened  and  drained.  Ha  bad,  howevei, 
treated  three  cases  in  a  manner  similar  to  that  adopted  by  myself. 
Thegr  all  aarvived,  but  only  after  g«Mng  throogh  a  proeeas  of  of- 
ftnaive  auppuratiou  tliat  hwted  far  Moatiw  mH  ft«t  nearly  kfflad 
them  all.  Theoretically,  the  method  of  closing  the  ne  ought  to 
give  good  reaulta,  but  in  practice  I  am  afraid  anbsequent  sup- 
poratkn  wBl  b»  foottd  to  e«Bttr. 

And  now,  gentlemen,  allow  me  to  thank  you  for  your  patient 
hearing.  This  evening's  address  has  given  you  the  result  of  part 
of  nqr^Bwoik.  BMOrda  hafv»  bean  earefolfy  kept  for  tUa  pmw 
pose  and  I  cannot,  in  my  lifetime,  reduplicate  them.  Lawsott 
Tait,  my  brilliant  and  much-admired  master,  has  already  jMuaed 
into  great  bqrond,  but  not  before  he  had  instilled  into  me, 
and  into  others  who  had  the  benefit  of  his  teaching,  the  habit  of 
keeping  accurate  records  of  cases  requiring  abdominal  operationa. 
To  tibis  habit  you  owe  the  preaentatim  oi  thaae  eaaea  and  tbe  ka- 
aons  to  be  drawn  from  them. 

I  feel  that  I  have  been  greatly  hmuaad  by  your  AMoetaHoii  ud 
will  atways  eury  witt  me  a  pleaaaat  raoo&etkm  <tf  Ha  aeatai  to 

1902. 

in  SBnaODBMK  STBER. 


